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, L1843, L1843 and L1852. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 77%.
Top Medical Necessity Denial Reasons
- Addition code is not reasonable and necessary.
- 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 A52465.
- Medical record documentation does not demonstrate knee instability by examination of the beneficiary. Refer to Local Coverage Determination L33318 and Policy Article A52465.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Standard written order (SWO) is signed after the claim was submitted. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.4 & Standard Documentation Requirements A55426.
- 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.
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.
