Ostomy Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) A4409, A4414, A4425, A5063, A4432, A4406, A4385, and A4394 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 - September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 16%.

Top Medical Necessity Denial Reasons

  • The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 & Standard Documentation Requirements A55426.
  • The quantity billed exceeds the usual maximum quantity of supplies.

Top Technical Denial Reasons

  • Related item denied due to invalid Standard Written Order (SWO).
  • Related Item Denied: Overutilization
  • Claim is billed for items which are not billable to the DME MAC.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.

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