Ostomy Supplies (HCPCS A4414 and A4407) Quarterly Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS code(s) A4414 and A4407. The quarterly edit effectiveness results from July 2021 through September 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 43% for HCPCS A4414.

Based on dollars, the overall claim potential improper payment rate is 44% for HCPCS A4407.

Top Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.
  • Refill request was not received.
  • The medical record documentation is dated after the date of service. Refer to A55426.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.

 

Last Updated Nov 15 , 2021