Ostomy 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 codes A4385, A4394, A4407, A4409, A4414, A4430, A5061 and A5063. The quarterly edit effectiveness results from July 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 21%.

Top Medical Necessity Denial Reasons

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

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letters.
  • 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.
  • The documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.

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 Wed, 02 Nov 2022 19:36:33 +0000