The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes A4407 and A4409. The final edit effectiveness results from April 2021 through July 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 27% for HCPCS A4407.

Based on dollars, the overall claim potential improper payment rate is 38% for HCPCS A4409.

Top Denial Reasons

• Documentation was not received in response to the Post-Payment Notification letter.
• No medical record documentation was received.
• Refill request is incomplete or was not received.
• Detailed Written Order (DWO) is incomplete or missing.
• Some or all of the medical record documentation is not applicable to this beneficiary.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy Supplies 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.