Surgical Dressings 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 codes A6010, A6021, A6023, A6196, A6197, A6209, A6212, A6222, A6252, A6253 and A6446. The quarterly edit effectiveness results from October 2023 - December 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 76%.

Top Medical Necessity Denial Reasons

  • Medical record documentation does not contain current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided.
  • Medical record documentation does not support the use of foam dressings when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.
  • Medical record documentation does not support the use of alginate or other fiber gelling dressing covers for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers).

Top Technical Denial Reasons

  • Claim includes items which are not billable to the DME MAC.
  • Standard written order (SWO) is missing the treating practitioner's signature. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 & Standard Documentation Requirements A55426.
  • 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.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Surgical Dressings 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 Jan 29 , 2024