Knee Orthosis Quarterly Results of Targeted Probe and Educate Review - JD DME
Knee 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) L1820, L1833 and L1852. The quarterly edit effectiveness results from January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 51%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s).
- Medical record documentation does not demonstrate knee instability by examination of the beneficiary.
- Addition code is not reasonable and necessary.
Top Technical Denial Reasons
- 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.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
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.
