Medical Review

Medical Record Review Results

Targeted Probe and Education (TPE) Reviews - CMS is resuming the Targeted Probe and Educate (TPE) program to help educate providers and reduce future denials and appeals. For more information on the TPE process, refer to the Targeted Probe and Educate page.

Service Specific Pre-Payment Reviews - Noridian has no current active Service Specific Pre-Payment Reviews. Prepayment reviews occur when a reviewer makes a claim determination before claim payment has been made. Prepayment reviews always result in an “initial determination.”

Service Specific Post-Payment Reviews - All post-payment reviews will be closed. Postpayment reviews occur when a reviewer makes a claim determination after the claim has been paid. Postpayment reviews result in either no change to the initial determination or a “revised determination” indicating that an overpayment or underpayment has occurred.

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Review Criteria Current
Error
Rate		 Review
Notification		 Quarterly
Review
Results
  • L1833: KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF
 78% View Notification View Quarterly Review Results
  • L1851: KNEE ORTHOSIS (KO), SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, OFF-THE-SHELF
 79% View Notification View Quarterly Review Results
  • A4414: OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
 42% View Notification View Quarterly Review Results
  • A4407: OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
 68% View Notification View Quarterly Review Results
  • A4351: INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
 52% View Notification View Quarterly Review Results
  • A4352: INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH
 53% View Notification View Quarterly Review Results
  • 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
 84% View Notification View Quarterly Review Results
  • L4361: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF
 42% View Notification View Quarterly Review Results
  • A6010: COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN
 74% View Notification View Quarterly Review Results
  • A6196: ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING
 83% View Notification View Quarterly Review Results
  • A6197: ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING
 95% View Notification View Quarterly Review Results
  • A4253: BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS
 88% View Notification View Quarterly Review Results
  • L0648: LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF
 33% View Notification View Quarterly Review Results
  • L0650: LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF
 69% View Notification View Quarterly Review Results

 

Resources

CMS Internet Only Manual (IOM), Publication 100-08, Chapter 3

 

Last Updated Wed, 15 Sep 2021 14:16:23 +0000