The Jurisdiction D, DME MAC, Medical Review Department is conducting Targeted Probe and Educate (TPE) reviews of HCPCS code J1559 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2026 – September 2026 are as follows:

Based on dollars, the overall claim potential improper payment rate is 10%.

Top Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• Related item denied due to invalid order.
• 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.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the External Infusion Pumps 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.