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 codes E0424, E0431, E1390, E1392 and K0738. The quarterly edit effectiveness results from January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 19%.
Top Medical Necessity Denial Reasons
- 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.
- Medical record documentation does not support the blood gas study was obtained within two days of discharge from an inpatient hospital stay.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service.
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.
