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 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 - September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 24%.

Top Medical Necessity Denial Reasons

  • The 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.
  • The medical record documentation does not support the beneficiary requires stabilization for medical reasons. Refer to Local Coverage Determination L33686 and Policy Article A52457.
  • The medical record documentation does not support the beneficiary has the potential to benefit functionally. Refer to Local Coverage Determination L33686 and Policy Article A52457.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Claim is the same or similar to another claim on file.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.

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.

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