The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes A4351, A4352, A4353, A4358 & A4359. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 26%.

Top Medical Necessity Denial Reasons

• The medical record documentation does not demonstrate the medical necessity for use of a Coude tip catheter.
• The medical record documentation does not indicate the beneficiary resides in a nursing facility; is immunosuppressed; has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization; is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only); OR has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits.
• No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.

Top Technical Denial Reasons

• The medical record documentation contains an error not otherwise specified.
• The claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 5.9 and applicable Local Coverage Determination/Policy Article.
• 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 Urological Supplies 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.