Urological Supplies Quarterly Results of Targeted Probe and Educate Review - JD DME
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 code(s) A4351, A4352, and A4353 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from October 2025 - December 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 12%.
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 records do not support the quantity billed. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
Top Technical Denial Reasons
- The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
- The date of service for item(s) billed has paid to another supplier. Refer to CMS Manual Pub 100-02 Chapter 15, Section 50.5.1-50.6 &110-140.
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.
