Positive Airway Pressure (PAP) Devices Quarterly Results of Targeted Probe and Educate Review - JD DME
Positive Airway Pressure (PAP) Devices 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) E0601. The quarterly edit effectiveness results from January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 12%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test.
- Clinical evaluation does not include an assessment of the beneficiary for obstructive sleep apnea.
- Medical record documentation does not contain a sleep test.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Related item denied: Order
- Related item denied: Overutilization
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the PAP Devices 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.
