Surgical Dressings Quarterly Results of Targeted Probe and Educate Review - JA DME
Surgical Dressings 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) A6010, A6021, A6196, A6197, A6199, A6212, A6220 and A6252. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 38%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not contain current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided.
- Medical record documentation does not support the surgical dressings are required for the treatment of a wound caused by, or treated by, a surgical procedure; or that they are required after debridement of a wound.
- Evaluation of the patient’s wound does not include its size (length x width in cm.) and depth.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter
- Standard written order (SWO) is expired per length of need.
- The medical record documentation is missing the beneficiary's name. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
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.
