Pneumatic Compression Devices (PCD) Quarterly Results of Targeted Probe and Educate Review - JA DME

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0651. The quarterly edit effectiveness results from April 2024 – June 2024 are as follows:

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

Top Medical Necessity Denial Reasons

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

Top Technical Denial Reasons

• Supply or accessory is denied as the base equipment is denied. Refer to applicable Local Coverage Determination/Policy Article.
• 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.
• Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.

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.