Pneumatic Compression 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 E0651. The quarterly edit effectiveness results from July 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 45%.

Top Medical Necessity Denial Reasons

  • The medical record does not support the lymphedema is documented to be unresponsive to other clinical treatment over the course of a required four-week trial.
  • The medical record documentation does not include a four-week trial of conservative therapy demonstrating failed response to treatment is required.
  • The medical record does not include documentation by the treating practitioner of the medical necessity of a pneumatic compression device including the patient’s diagnosis and prognosis; symptoms and objective findings, including measurements which establish the severity of the condition; the reason the device is required, including the treatments which have been tried and failed; and the clinical response to an initial treatment with the device.

Top Technical Denial Reasons

  • The supply or accessory is denied as the base equipment is denied. Refer to applicable Local Coverage Determination/Policy Article.
  • The 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.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Pneumatic Compression 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.

 

Last Updated Wed, 02 Nov 2022 19:36:43 +0000