Surgical Dressing Supplies 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, A6196, A6197, A6209, A6212, A6252, A6253 & A6446. The quarterly edit effectiveness results from October 2022 - December 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 48%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not contain current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided.
  • The 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.
  • The evaluation of the patient’s wound does not include its size (length x width in cm.) and depth.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The 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.
  • The claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 5.9 and applicable Local Coverage Determination/Policy Article.

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 Wed, 18 Jan 2023 15:46:19 +0000