Ostomy Supplies Quarterly Results of Targeted Probe and Educate Review - JA DME
Ostomy Supplies 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) A4385, A4394, A4406, A4409, A4414, A4425, A4432 and A5063. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 15%.
Top Medical Necessity Denial Reasons
- Quantity billed exceeds the usual maximum quantity of supplies.
- Medical record documentation does not support a covered diagnosis.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Related item denied: Overutilization
- Related item denied: Order
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.
