Spinal Orthosis Quarterly Results of Targeted Probe and Educate Review - JA DME
Spinal 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) L0631 and L0637. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 46%.
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.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
- Medical record documentation does not demonstrate a change in the patient's medical condition necessitating a different item.
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.
