Ostomy (HCPCS A4385 & A4414) Final Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes A4385 and A4414. The final edit effectiveness results from September 2021 through November 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 47% for HCPCS A4385.

Based on dollars, the overall claim potential improper payment rate is 58% for HCPCS A4414.

Top Denial Reasons

  • No medical record documentation was received. Refer to Medicare Program Integrity Manual
  • Documentation was not received in response to the Post-Payment Notification Letter.
  • Refill request was not received.
  • Claim is billed for greater quantity than Detailed Written Order (DWO) indicates.
  • Detailed Written Order (DWO) was not received.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.


Last Updated Fri, 14 Jan 2022 13:42:04 +0000