Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L1970, L4360, L4361) Notification of Service Specific Prepayment Targeted Review
Noridian Jurisdiction A, DME MAC, Medical Review will be initiating a service specific prepayment targeted review of claims for each of the following HCPCS code(s).
- L1970: ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED
- L4360: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE
- L4361: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF
Service specific targeted reviews are initiated to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis. This review is being initiated based on a high Comprehensive Error Rate Testing (CERT) error rate.
In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction A for HCPCS codes listed above are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria.
- Treating physician's dispensing and written order
- Patient medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided are reasonable and necessary
- Justification to support the custom fitted or off-the-shelf orthosis code billed (if applicable)
- Documentation to support the medical necessity of custom fabricated rather than prefabricated orthosis (if applicable)
- Proof of delivery
- The Advance Beneficiary Notice of Noncoverage (if applicable)
- Any other supporting documentation
Failure to supply the above requested information within 45 days of the date of the letter will result in the claim being denied. Please fax or mail the requested documentation and a copy of the ADR letter. The ADR letter provided will also provide instruction for submitting documentation.
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 and Policy Article A52457 on the Active LCDs webpage.
Additional information, educational opportunities and training tools related to this product category are available in Education & Outreach.
Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3
Last Updated Jan 18, 2018