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) L1843, L1845 and L1852. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 26%.
Top Medical Necessity Denial Reasons
- Documentation does not demonstrate more than the minimal self adjustment modifications were performed to the prefabricated orthosis.
- Medical record documentation does not demonstrate an objective description of joint laxity.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- No medical record documentation was received.
- Documentation does not include a standard written order (SWO).
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.
