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, L1843, L1845 and L1852. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 11%.
Top Medical Necessity Denial Reasons
- Documentation does not include a detailed description of the modifications necessary for the item requiring more than minimal self-adjustment by a qualified practitioner at the time of fitting the orthosis. Refer to applicable Local Coverage Determination/Policy Article.
Top Technical Denial Reasons
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
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.
