Urological 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 A4351, A4352 and A4353. The quarterly edit effectiveness results from July 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 29%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support permanent urinary incontinence or permanent urinary retention.
  • The medical record documentation does not demonstrate the medical necessity for use of a Coude tip catheter.
  • The medical record documentation does not indicate the beneficiary resides in a nursing facility; is immunosuppressed; has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization; is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only); OR has had distinct, recurrent urinary tract infections, while on a program of sterile intermittent catheterization with A4351/A4352 and sterile lubricant A4332, twice within the 12-month prior to the initiation of sterile intermittent catheter kits.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The face-to-face encounter is not authenticated (handwritten or electronic) by the author. Refer to 42 Code of Federal Regulations 410.38 (c) & Medicare Program Integrity Manual 100-08, Chapter 3, Section
  • The 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 Urological Supplies 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, 02 Nov 2022 19:37:20 +0000