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 codes A6010, A6021, A6196, A6197, A6212, A6252 and A6446. The quarterly edit effectiveness results from April 2022 - June 2022 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 need for additional tape or another dressing as a wound cover with an adhesive border is being used.
  • 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.
  • Standard Written Order (SWO) was not received.
  • Claim is billed for items which are not billable to the DME MAC.

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.


Last Updated Tue, 26 Jul 2022 18:43:30 +0000