Oxygen and Oxygen Equipment Quarterly Results of Targeted Probe and Educate Review - JD DME
Oxygen and Oxygen Equipment 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) E0424, E0431, E1390 and E1392. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 13%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the blood gas study was obtained within two days of discharge from an inpatient hospital stay. Refer to National Coverage Determination 240.2 & Local Coverage Determination L33797.
- Medical record documentation does not support the treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed. Refer to National Coverage Determination 240.2, Local Coverage Determination L33797, & Policy Article A52514.
- Medical record documentation does not contain a qualifying blood gas study performed at rest (awake) or during exercise to support a portable oxygen system. Refer to National Coverage Determination 240.2 & Local Coverage Determination L33797.
Top Technical Denial Reasons
- 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.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Oxygen 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.
