Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L1970, L4360 and L4361. The quarterly edit effectiveness results from January 1, 2020 – March 31, 2020 are as follows:

Based on dollars, the overall claim potential improper payment rate is 25%.

Top Denial Reasons

  • Documentation does not support coverage criteria.
  • Claim is the same or similar to another claim on file.
  • Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.
  • The item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.


Last Updated Mon, 04 May 2020 16:55:53 +0000