Urological Supplies (HCPCS A4351 & A4352) Final Edit Effectiveness Results of Service Specific Post-Payment Review - JA DME

The Jurisdiction A, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS code(s) A4351 and A4352. The final edit effectiveness results from September 2021 through November 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 38% for HCPCS A4351.

Based on dollars, the overall claim potential improper payment rate is 70% for HCPCS A4352.

Top Denial Reasons

• Documentation was not received in response to the post-payment notification letter.
• Documentation does not support coverage criteria.
• Medical record documentation was not authenticated (handwritten or electronic) by the author.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Urological Supplies webpage to access coverage documents.

• National Coverage Determination (NCD)
• Local Coverage Determination (LCD)
• Policy Article
• Documentation letters, forms, and checklists
• Review tips, tools, and resources
• Related articles
• Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.