Oxygen Quarterly Results of Targeted Probe and Educate Review - JA DME
Oxygen 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) E0424, E0431, E1390, E1392 and K0738. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 13%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support a valid blood gas study obtained during exercise. Refer National Coverage Determination 240.2 & Local Coverage Determination L33797.
- Medical record documentation does not support any of the Group I criteria. Refer to National Coverage Determination 240.2 & Local Coverage Determination L33797.
- Medical record documentation does not support the treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed. Refer to National Coverage Determination 240.2, Local Coverage Determination L33797, & Policy Article A52514.
Top Technical Denial Reasons
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
- 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 Oxygen 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.
