DME contractors perform pre- and post-payment reviews on a continual basis. Through data analysis, the medical review department determines the codes they will review and then sends Additional Documentation Request letters to suppliers that bill those codes.
The following list includes those codes currently being reviewed among two or more DME jurisdictions:
- Noninvasive vents (E0464)
- CPAPs (E0601)
- Test strips (A4253)
- Diabetic shoes (A5500)
- Hospital beds (E0260)
- Group 2 pressure reducing support surfaces (E0277)
- Vacuum Erection Devices (L7900)
- Oxygen (E1390, E0431, E0434, E0439)
- Immunosuppressive Drugs (J7507, J7517, J7518, J7520)
- Nebulizers and drugs (E0570,J7605, J7606, J7613, J7620, J7626)
- Enteral nutrition (B9000, B9002, B4150, B4154)
Strategic Health Solutions is the supplemental medical review contractor responsible for conducting nationwide medical review as directed by CMS. Past DMEPOS projects included power mobility devices and Vacuum Erection Devices. Currently, SHS is conducting reviews of diabetic testing strips (A4253).
SHS audit requests consist of 100 claims, regardless of business size. Like other audit contractors, SHS notifies the supplier of the results of the audit, then recommends the claims for overpayment to the DME MAC. The audit can result in an overpayment of the claims audited and/or an extrapolated overpayment of the claims universe during the time period reviewed. To date, vHG clients have received overpayment notifications for VEDs on individual claims rather than extrapolated overpayments. Our clients have begun receiving audit results letters for diabetic testing strips, but are currently awaiting the overpayment demand letters from the DME MACs. Therefore, the results of these audits to be individual or extrapolated overpayments are to be determined.