Knee Orthoses (HCPCS L1832, L1833) Final Edit Effectiveness Results of Service Specific Prepayment Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code L1832 and L1833. The final edit effectiveness results from July 2017 through November 2017 are as follows:
The L1832 review involved 180 claims, of which 179 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99%.
The L1833 review involved 754 claims, of which 662 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 88%.
Top Denial Reasons
- Documentation does not support coverage criteria.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not support custom fit criteria.
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Knee Orthoses Local Coverage Determination (LCD) L33318, Policy Article A52465 [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 Knee 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.
Knee orthoses K0901, K0902, L1832, L1833, L1843 and L1845 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Diagnosis Codes That Support Medical Necessity Group 4 Codes section.
For codes K0901, K0902, L1832, L1833, L1843, L1845 and L1850, 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 for K0901, K0902, L1832, L1833, L1843, L1845 or L1850 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.
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 in order 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 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.
Claims for custom fitted orthoses (L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0626, L0627, L0630, L0631, L0633, L0635, L0637 and L0639) will be denied as incorrect coding, with a statutory denial, when documentation shows that only minimal self-adjustment was required at the time of fitting (see Policy Specific Documentation Requirements section in the Local Coverage Determination).
Last Updated Jan 18, 2018