Ostomy (HCPCS A4385 & A4414) Quarterly 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 quarterly edit effectiveness results from June 2021 through August 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 31% for HCPCS A4385.

Based on dollars, the overall claim potential improper payment rate is 60% for HCPCS A4414.

Top Denial Reasons

  • Documentation was not received in response to the Post-Payment Notification Letter.
  • The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.
  • Refill request documentation is incomplete or missing elements.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual
  • Claim is billed for greater quantity than Detailed Written Order (DWO) indicates.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics 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 Wed, 20 Oct 2021 16:19:01 +0000