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 October 2025 - December 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 11%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support a covered diagnosis.

Top Technical Denial Reasons

  • Related item denied due to invalid Standard Written Order (SWO).
  • Related item denied due to overutilization.
  • No medical record documentation received.

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.

Last Updated Jan 28 , 2026