The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes A4407, A4409, A4416, A4424 and A4425. The quarterly edit effectiveness results from October 2022 - December 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 20%.

Top Medical Necessity Denial Reasons

• N/A

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.

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.