The Jurisdiction D, DME MAC, Medical Review Department is conducting Targeted Probe and Educate (TPE) reviews of HCPCS codes A4295, A4296, A4297, A4326, A4351, A4352 and A4353 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2026 – September 2026 are as follows:

Based on dollars, the overall claim potential improper payment rate is 13%.

Top Denial Reasons

• The medical records do not support the quantity billed. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.
• The medical record documentation does not support permanent urinary incontinence or permanent urinary retention.
• No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9.

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.