The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes L0627, L0631, L0637 & L0642. The quarterly edit effectiveness results from January 2023 - March 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 93%.

Top Medical Necessity Denial Reasons

• The documentation does not demonstrate more than minimal self adjustment modifications were performed to the prefabricated orthosis.
• The medical record documentation does not demonstrate the spinal orthosis is indicated to reduce pain by restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine. Refer to Local Coverage Determination L33790 and Policy Article A52500.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.  Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426.
• Claims history indicates same or similar durable medical equipment within the last five years. Refer to Medicare Benefit Policy Manual Chapter 15, Section 110.2 (C).

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.