Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) 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 has weakness or deformity of the foot and ankle. Refer to Local Coverage Determination L33686 and Policy Article A52457.

Top Technical Denial Reasons

  • N/A

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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