Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review - JD DME
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 July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 17%.
Top Medical Necessity Denial Reasons
- Medical record documentation indicates the item is needed during post-operative recovery; however, the surgery has not yet taken place. Refer to Medicare Benefit Policy Manual Chapter 15, Section 110.1, Section C.
- Medical record documentation does not support the beneficiary is ambulatory. Refer to Local Coverage Determination L33686 and Policy Article A52457.
- 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
- 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.
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
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.
