Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review - JA DME
Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L4350, L4360 & L4361. The quarterly edit effectiveness results from January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 8%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary has weakness or deformity of the foot and ankle. Refer to Local Coverage Determination L33686 and Policy Article A52457.
Top Technical Denial Reasons
- Claim submitted is a duplicate to another claim billed.
- Claims history indicates same or similar durable medical equipment within the last five years. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50.1.
- Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics 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.
