Medical Review

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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 Prepayment Reviews - Noridian has no current active Service Specific Prepayment 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. Post-payment reviews occur when a reviewer makes a claim determination after the claim has been paid. Post-payment reviews result in either no change to the initial determination or a “revised determination” indicating that an overpayment or underpayment has occurred.

Supplier compliance results for all TPE reviews completed from January 2022 - March 2022 included:

  • 10-Claim Preview - 15% compliance
  • Round 1 - 50% compliance
  • Round 2 - N/A
  • Round 3 - N/A
X
 

TPE Pre-Payment Reviews

Review Criteria Current
Error
Rate		 Current Review Results
Ankle-Foot Orthosis (AFO) TPE Reviews 32% View Current Review Results
Diabetic Supplies TPE Reviews 74% View Current Review Results
Knee Orthosis TPE Reviews 44% View Current Review Results
Manual Wheelchairs TPE Reviews 55% View Current Review Results
Ostomy Supplies TPE Reviews 7% View Current Review Results
Spinal Orthosis TPE Reviews 24% View Current Review Results
Surgical Dressings TPE Reviews 42% View Current Review Results
Therapeutic Shoes TPE Reviews 64% View Current Review Results
Urological Supplies TPE Reviews 26% View Current Review Results

 

Post-Payment Reviews

Review Criteria Current
Error
Rate		 Review
Notification		 Quarterly
Review
Results		 Final Results
  • L1833: KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF
 74% View Notification View Quarterly Review Results View Final 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
 93% View Notification View Quarterly Review Results View Final Review Results
  • A4414: OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
 51% View Notification View Quarterly Review Results View Final 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
 67% View Notification View Quarterly Review Results View Final Review Results
  • A4351: INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
 38% View Notification View Quarterly Review Results View Final Review Results
  • A4352: INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH
 70% View Notification View Quarterly Review Results View Final 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
 77% View Notification View Quarterly Review Results View Final Review Results
  • L4361: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF
 28% View Notification View Quarterly Review Results View Final Review Results
  • A6010: COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN
 100% View Notification View Quarterly Review Results View Final Review Results
  • A6196: ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING
 88% View Notification View Quarterly Review Results View Final 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
 100% View Notification View Quarterly Review Results View Final Review Results
  • A4253: BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50 STRIPS
 84% View Notification View Quarterly Review Results View Final 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
 46% View Notification View Quarterly Review Results View Final 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
 60% View Notification View Quarterly Review Results View Final Review Results

 

Resources

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

 

Last Updated Fri, 29 Apr 2022 13:48:33 +0000