The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS code(s) A4407 and A4409. The quarterly edit effectiveness results from January 2021 through March 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 35% for HCPCS A4407.

Based on dollars, the overall claim potential improper payment rate is 46% for HCPCS A4409.

Top Denial Reasons

• Documentation was not received in response to the Post-Payment Notification letter.
• Refill request was not received.
• No medical record documentation was received.
• Claim is billed for items which are not billable to the DME MAC.
• Documentation does not support coverage criteria.
• The documentation was not timely (within the preceding 12 months) to support continued need by the 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.