CERT Errors - Knee Orthoses

The CERT Review Contractor is currently reviewing claims related to Knee Orthoses. Noridian has reviewed and listed the top Comprehensive Error Rate Testing (CERT) error comments in efforts to assist suppliers by preventing or eliminating errors, particularly for the L1843 Knee Orthoses Single upright custom fit; L1851 Knee Orthoses single upright prefabricated, off-the-shelf and L1833 adjustable knee joints. Most of the CERT denial reasons noted by Noridian relate to clinical records supporting the medical need of the knee orthosis and proof of delivery issues.

CERT Error Comment: Missing Treating physician or practitioner’s clinical record documenting the beneficiary has had recent injury to or a surgical procedure on the knee(s); or who is ambulatory and has knee instability as documented by objective description of joint laxity.

Examples of appropriate documentation that would qualify for medical necessity for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 would include:

  • Documentation if the beneficiary has had a recent injury to or a surgical procedure on the knee(s) or
  • Documentation if the beneficiary is ambulatory and has knee instability due to a condition specified in Group 4 ICD-10 Codes in the LCD-related Policy Article A52465.
    1. Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

CERT Error Comment: Missing proof of delivery for billed orthosis

Examples of appropriate documentation that would qualify for a valid proof of delivery (POD) for method 1 (Direct Delivery to the Beneficiary by the Supplier):

  • Beneficiary’s name
  • Delivery address
  • A description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number
  • Quantity delivered
  • Date delivered
  • Beneficiary (or designee) signature

The date delivered on the POD must be the date that the DMEPOS item was received by the Beneficiary or designee. The date of delivery may be entered by the beneficiary, designee, or the supplier. When the supplier’s delivery documents have both a supplier-entered date and a beneficiary or beneficiary’s designee signature date on the POD document, the beneficiary (or designee) entered date is the date of service (DOS).

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the DOS on the claim.

Examples of appropriate documentation that would qualify for a valid proof of delivery for method 2 (Delivery via Shipping or Delivery Service Directly to a Beneficiary).

If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable POD would include both the supplier’s own detailed shipping invoice and the delivery service’s tracking information. The supplier’s record must be linked to the delivery service record by some clear method like the delivery service’s package identification number or supplier’s invoice number for the package sent to the beneficiary. The POD document must include:

  • Beneficiary’s name
  • Delivery address
  • Delivery service’s package identification number, supplier invoice number or alternative method that links the supplier’s delivery documents with the delivery service’s records.
  • A description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number
  • Quantity delivered
  • Date delivered
  • Evidence of delivery

If a supplier utilizes a shipping service or mail order, suppliers have two options for the DOS to use on the claim:

  1. Suppliers may use the shipping date as the DOS. The shipping date is defined as the date the delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation.
  2. Suppliers may use the date of delivery as the DOS on the claim.
  3. Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as POD. This type of POD document must contain the information specified above.

As a general reminder when submitting documentation for reviews, it is important to follow the signature requirements for medical documentation. The requirements are listed below:

Program Integrity Manual (PIM) 3.3.2.4 - Signature Requirements - (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) This section is applicable for MACs, UPICs, SMRCs, CERT and RACs as indicated.

For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. For example, if the physician’s authenticated documentation corroborates the nurse’s unsigned note, and the physician was the responsible party per Medicare’s payment policy, medical reviewers would consider signature requirements to have been met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.

 

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