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) A6197, A6196, A6021, A6212, A6252, A6199, A6253, A6210, A6220, and A6209 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 - September 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 19%.
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.
- Related item: Documentation does not support medical necessity.
- The medical record documentation does not support the necessity of greater quantities than a one month's supply of dressings at one time.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Related item denied due to invalid Standard Written Order (SWO).
- The date of service for item(s) billed has been paid.
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.
