The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes A6010, A6021, A6196, A6197, A6212 & A6252. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 39%.

Top Medical Necessity Denial Reasons

• The medical record documentation does not contain current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided.
• The medical record documentation does not support the use of foam dressings when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.
• The evaluation of the patient’s wound does not include the amount of drainage.

Top Technical Denial Reasons

• The claim includes items which are not billable to the DME MAC.
• The date of service for item(s) billed has been partially paid. Refer to CMS Manual Pub 100-02 Chapter 15, Section 50.5.1-50.6 & 110-140.
• 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 Surgical Dressings 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.