Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L1970, L4360, L4361) Quarterly Results of Service Specific Prepayment Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code(s) L1970, L4360 and L4361. The quarterly edit effectiveness results from April 2017 through July 2017 are as follows:
The L1970 review involved 82 claims, of which 70 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 83%.
The L4360 review involved 165 claims, of which 160 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 97%.
The L4361 review involved 384 claims, of which 277 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 71%.
Top Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not support custom fit criteria.
- Proof of Delivery (POD) was not received.
- Claim is same or similar to another claim on file.
Based on the results of this review, Noridian will continue with the Prepayment Service Specific Review.
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Ankle-Foot/Knee-Ankle-Foot Orthosis Local Coverage Determination (LCD) L33686, Policy Article A52457 [PDF] and Standard Documentation Requirements Article A55426 (effective 1/1/2017).
Suppliers can also review specific policy resources for Orthotics and Prosthetics on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during web-based workshops.
Suppliers can also review a specific policy Documentation Checklist for Ankle-Foot/Knee-Ankle-Foot Orthosis on the Noridian website.
Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.
Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 .
Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).
Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian's website.
Custom fitted orthotics are:
- Devices that are prefabricated
- They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
- Classification as custom fitted requires substantial modification for fitting at the time of delivery to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
- This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.
Substantial modification is defined as changes made to achieve an individualized fit of the item during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.
Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.
POD documentation, as well as claims documentation, must be maintained in the supplier's files for 7 years (starting from the date of service).
Suppliers, their employees, or anyone else having a financial interest in the delivery of the item(s) are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier (i.e., spouse, neighbor). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.
For the purpose of the delivery methods noted below, designee is defined as any person who can sign and accept the delivery of DMEPOS on behalf of the beneficiary.
The supplier should also have on file any documentation containing a description of the item delivered to the beneficiary to determine the accuracy of claims coding including, but not limited to, a voucher, invoice or statement in the supplier records. There must be a sufficient level of detail in the item description to definitively determine the appropriate HCPCS to be appended to the claim. The long description of the HCPCS code, may be used to provide a detailed description of the item being delivered.
Proof of delivery documentation must be available to the Medicare contractor on request. All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested. Suppliers who consistently fail to provide documentation to support their services may be referred to the Office of Inspector General (OIG) or the National Supplier Clearinghouse for investigation and/or imposition of sanctions.
There are three methods of delivery. Regardless of the method of delivery, the contractor must be able to determine that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) were received by a specific beneficiary:
- Delivery directly to the beneficiary or authorized representative
- Delivery via shipping or delivery service
- Delivery of items to a nursing facility on behalf of the beneficiary
Method 1—Direct Delivery to the Beneficiary by the Supplier
Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery document. The POD document must include:
- Beneficiary's name
- Delivery address
- Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered
- 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.
In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.
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
- Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used to provide a detailed description of the item being delivered
- Quantity delivered
- Date delivered
- Evidence of delivery
If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service on the claim.
Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This type of POD document must contain the information specified above.
Method 3—Delivery to Nursing Facility on Behalf of a Beneficiary
For items directly delivered by the supplier to a nursing facility or when a delivery service or mail order is used to deliver the item(s) to a nursing facility, the supplier must have:
- Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and
- Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.
Same or similar denials occur when the patient's CMN history indicates a piece of equipment is the same or like the equipment being billed.
To determine whether same or similar items have previously been provided, suppliers must obtain all possible information from a patient, which may include the following:
- Patient's correct Health Insurance Claim number;
- Whether the patient has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
- If the patient currently has or had an identical or similar item in the past;
- When the patient received the items and whether or not the items have been returned;
- Where the item will be used; and
- CMN or DIF information, if required.
By using the Suggested Intake Form, it assures this information is obtained. This form is available on our website under the Forms section and it contains beneficiary information, ordering physician information and questions for the beneficiary and the supplier. Suppliers can customize their own intake form to meet their needs as well.
The Noridian Medicare Portal or Interactive Voice Response System can be used to verify that a beneficiary has not had a same or similar item within the previous five years. Follow the steps listed under the manual on the Noridian Medicare Portal to check for same or similar items.
Last Updated Sep 13, 2017