Urological Supplies Quarterly Results of Targeted Probe and Educate Review - JA DME
Urological Supplies 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) A4351, A4352, and A4353 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 5%.
Top Medical Necessity Denial Reasons
- The medical record documentation does not support permanent urinary incontinence or permanent urinary retention.
- The medical records do not support the quantity billed. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
Top Technical Denial Reasons
- The standard written order (SWO) is missing the treating practitioner's signature. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 & Standard Documentation Requirements A55426.
- 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.
