Positive Airway Pressure (PAP) Devices Quarterly Results of TPE 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 E0601. The quarterly edit effectiveness results from October 2023 - December 2023 are as follows:
Based on dollars, the overall claim potential improper payment rate is 17%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not include documentation the beneficiary had a sleep test, prior to fee for service (FFS) Medicare enrollment that meets Medicare coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of replacement PAP device. Refer to Local Coverage Determination L33718 & Policy Article A52467.
- Medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
- Clinical evaluation does not include an assessment of the beneficiary for obstructive sleep apnea. Refer to Local Coverage Determination L33718.
Top Technical Denial Reasons
- Medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.
- Some or all of the medical record documentation is not applicable to this beneficiary. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
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.
