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) L1971, L4360 & L4361. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 35%.

Top Medical Necessity Denial Reasons

  • Medical record documentation does not support the beneficiary requires stabilization for medical reasons.
  • Medical record documentation does not support the beneficiary has the potential to benefit functionally.
  • Documentation does not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.

Top Technical Denial Reasons

  • Medical record documentation is dated after the date of service.
  • Claim submitted is a duplicate to another claim billed.
  • Beneficiary was in an acute care hospital or skilled nursing facility on this date of service.

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 Apr 22 , 2024