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)

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.