Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review - JA DME
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 July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 15%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary is ambulatory.
- Medical record documentation does not indicate medical necessity for the item at the time of delivery.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Claim submitted is a duplicate to another claim billed.
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
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.
