Surgical Dressings Quarterly Results of Targeted Probe and Educate Review - JD DME

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) A6010, A6021, A6023, A6196, A6197, A6209, A6212, A6219, A6222, A6252, A6253 and A6446. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 35%.

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 alginate or other fiber gelling dressing covers for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers).
• Medical record documentation does not support a monthly evaluation of the patient's wound(s) or documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• Claim includes items which are not billable to the DME MAC.
• Related item denied: Overutilization

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.