Ankle-Foot Orthosis (HCPCS L4360 & L4361) Final Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS code(s) L4360 and L4361. The final edit effectiveness results from September 2021 through November 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 77% for HCPCS L4360.

Based on dollars, the overall claim potential improper payment rate is 28% for HCPCS L4361.

Top Denial Reasons

  • Documentation does not support custom fit criteria.
  • Documentation was not received in response to the post-payment notification letter.
  • Medical record documentation was not authenticated (handwritten or electronic) by the author.
  • Documentation does not support coverage criteria.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.


Last Updated Tue, 28 Dec 2021 19:44:21 +0000