Knee Orthosis Quarterly Results of Targeted Probe and Educate Review - JA DME
Knee 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) L1833 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 61%.
Top Medical Necessity Denial Reasons
- The medical record documentation does not demonstrate knee instability by examination of the beneficiary. Refer to Local Coverage Determination L33318 and Policy Article A52465.
- The medical record documentation does not demonstrate knee instability due to an applicable group 4 diagnosis code. Refer to Local Coverage Determination L33318 and Policy Article A52465.
- The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s). Refer to local coverage determination L33318 and policy article 52465.
Top Technical Denial Reasons
- The addition code is not reasonable and necessary.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.
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.
