The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code E0651. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 68%.

Top Medical Necessity Denial Reasons

• The medical record documentation does not include a four-week trial of conservative therapy demonstrating failed response to treatment is required.
• The medical record does not include symptoms and objective findings, including measurements which establish the severity of the condition.
• The medical record does not include the clinical response to an initial treatment with the device.

Top Technical Denial Reasons

• The supply or accessory is denied as the base equipment is denied. Refer to applicable Local Coverage Determination/Policy Article.
• The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.
• The medical record documentation contains an error not otherwise specified.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Pneumatic Compression Devices 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.