Surgical Dressings Quarterly Results of Targeted Probe and Educate Review - JD DME
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 code(s) A6010, A6021, A6023, A6196, A6197, A6209, a6210, A6212, A6219, A6222, A6252, A6253 and A6446. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 24%.
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 the use of foam dressings when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.
Top Technical Denial Reasons
- Claim includes items which are not billable to the DME MAC.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- 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.
