Ostomy Supplies Quarterly Results of Targeted Probe and Educate Review - JD DME
Ostomy Supplies 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) A4409, A4385, and A5057 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 – September 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 14%.
Top Medical Necessity Denial Reasons
- The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 & Standard Documentation Requirements A55426.
Top Technical Denial Reasons
- 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.
- Related item denied due to invalid Standard Written Order (SWO).
- Related Item Denied: Overutilization
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy 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.
