Hospital Beds Quarterly Results of TPE Review - JD DME
Hospital Beds Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0260 and E0295. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 18%.
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
- Treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
- 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.
