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WoundReference Editors WoundReference Editors, | Updated on May 21, 2024

As published by the Medicare Administrative Contractor (MAC) WPS Government Health Administrators on 4/15/2024, the service with the second highest error rate in a recent Targeted Probe and Educate (TPE) review was Wound Care. Top reason for denial is related to lack of documentation that supports medical necessity, as shown below. 

MACs conduct TPE reviews to decrease provider burden, reduce appeals, and improve the medical review/education process. To avoid errors, providers should be aware of problem error rates and top reasons for denial.

Current Problem Error Rates for J5 Part A Option Year 3 (OY3)

ServiceError Rate
Spinal Injection – CPT 62323 
Wound Care
Medi-Medi Skilled Therapy – CPT 97110
Skilled Therapy – CPT 97150

Skilled Nursing Facility (SNF) Patient Driven Payment Model


Medi-Medi Skilled Therapy – CPT 97535

Inpatient Rehabilitation Facility (IRF) - CMG D0103 &



Top Reasons for Denial for Wound Care, the Service with the Second Highest Error Rate

  • GAJ06 – the claim does not support medical necessity as outlined in the MACs Local Coverage Determination (LCD)
  • GAJ01- the documentation submitted does not support medical necessity as listed in coverage requirements.

Additional information regarding each problem can be found on the Medical Review Guides and Resources web page.

About the Authors

WoundReference Editors,
The WoundReference Editorial Board is comprised of wound care and hyperbaric medicine clinicians with a diverse background, such as physicians, advanced practice registered nurses, physician assistants, wound continence and ostomy nurses, hyperbaric technologists, therapists, nutritionists and more.
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