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April 1, 2021

Widespread Post-Pay, Service-Specific Review Announcement – HCPCS Codes A4431, A4434, A5081, and A5122

CGS' Medical Review staff will be conducting a complex post-pay, service-specific medical review of HCPCS codes A4431, A4434, A5081, and A5122 (Ostomy Policy). This review will be conducted because data analysis revealed that Jurisdiction B's allowed dollars for HCPCS codes A4431, A4434, A5081, and A5122 were significantly above expected amounts. Additionally, the ostomy policy group ranked within the top #20 in total Comprehensive Error Rate Testing (CERT) errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in federal law at SSA 1833 (e) and in federal regulation at 42 CFR 424.5(a)(6). Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Treating practitioner's written order
  2. Documentation to support the reasonable and necessary and statutory requirements defined in the Local Coverage Determination (LCD) and related policy article
  3. Documentation to support the medical necessity for the quantity of supplies
  4. Proof of beneficiary’s or caregiver’s request for refill
  5. Any other pertinent documentation used to determine that the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item is reasonable and necessary
  6. Copy of Advance Beneficiary Notice (ABN), if one was obtained


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