Hospital Beds Quarterly Results of TPE Review - JD DME

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0260. The quarterly edit effectiveness results from April 2024 - June 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 35%.

Top Medical Necessity Denial Reasons

• Medical record documentation does not support the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.
• Medical record documentation does not support the beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, requires the head of the bed to be elevated more than 30 degrees, or requires traction equipment which can only be attached to a hospital bed.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
• Item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Hospital Beds 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.