Knee Orthosis Quarterly Results of Targeted Probe and Educate Review - JA DME
Knee 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) L1833. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 4%.
Top Medical Necessity Denial Reasons
- Addition code is not reasonable and necessary.
Top Technical Denial Reasons
- Standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 & Standard Documentation Requirements A55426.
- Standard written order (SWO) was signed prior to the date of the in-person visit with the treating practitioner. Refer to applicable Local Coverage Determination (LCD).
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.
