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 and L4361. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 5%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary requires stabilization for medical reasons. Refer to Local Coverage Determination L33686 and Policy Article A52457.
- Medical record documentation does not support the beneficiary has the potential to benefit functionally. Refer to Local Coverage Determination L33686 and Policy Articles A52457.
Top Technical Denial Reasons
- Claim submitted is a duplicate to another claim billed.
- Item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.
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.
