The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes A4352 and A4353. The quarterly edit effectiveness results from June 2021 through August 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 49% for HCPCS A4352.

Based on dollars, the overall claim potential improper payment rate is 77% for HCPCS A4353.

Top Denial Reasons

• Documentation does not support coverage criteria.
• Documentation was not received in response to the Post-Payment Notification Letter.
• Detailed Written Order (DWO) is incomplete or missing elements.
• No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.
• Medical record documentation was not authenticated (handwritten or electronic) by the author.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Urological Supplies webpage to access coverage documents.

• National Coverage Determination (NCD)
• Local Coverage Determination (LCD)
• Policy Article
• Documentation letters, forms, and checklists
• Review tips, tools, and resources
• Related articles
• Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.