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Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4361) Quarterly Results of Service Specific Prepayment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code(s) L4361. The quarterly edit effectiveness results from January 2017 through April 2017 are as follows:

The L4361 review involved 704 claims, of which 462 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 66%.

Top Denial Reasons

Going Forward

Based on the results of this review, Noridian will continue with the Prepayment Service Specific Review.

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Ankle-Foot/Knee-Ankle-Foot Orthosis Local Coverage Determination (LCD) L33686, Policy Article A52457 [PDF] and Standard Documentation Requirements Article A55426 (effective 1/1/2017).

Suppliers can also review specific policy resources for Ankle-Foot/Knee-Ankle-Foot Orthosis on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during web-based workshops.

Suppliers can also review a specific policy Documentation Checklist for Ankle-Foot/Knee-Ankle-Foot Orthosis on the Noridian website.

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.

Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 This link will take you to an external website..

Policy Education

Documentation was not received in response to the Additional Documentation Request (ADR) letter.

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).

Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian's website.

Proof of Delivery (POD) is incomplete or missing elements.

POD documentation, as well as claims documentation, must be maintained in the supplier's files for 7 years (starting from the date of service).

Suppliers, their employees, or anyone else having a financial interest in the delivery of the item(s) are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier (i.e., spouse, neighbor). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.

For the purpose of the delivery methods noted below, designee is defined as any person who can sign and accept the delivery of DMEPOS on behalf of the beneficiary.

The supplier should also have on file any documentation containing a description of the item delivered to the beneficiary to determine the accuracy of claims coding including, but not limited to, a voucher, invoice or statement in the supplier records. There must be a sufficient level of detail in the item description to definitively determine the appropriate HCPCS to be appended to the claim. The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered.

Proof of delivery documentation must be available to the Medicare contractor on request. All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested. Suppliers who consistently fail to provide documentation to support their services may be referred to the Office of Inspector General (OIG) or the National Supplier Clearinghouse for investigation and/or imposition of sanctions.

There are three methods of delivery. Regardless of the method of delivery, the contractor must be able to determine that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) were received by a specific beneficiary:

  • Delivery directly to the beneficiary or authorized representative
  • Delivery via shipping or delivery service
  • Delivery of items to a nursing facility on behalf of the beneficiary

Method 1—Direct Delivery to the Beneficiary by the Supplier
Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery document. The POD document must include:

  • Beneficiary's name
  • Delivery address
  • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered
  • Quantity delivered
  • Date delivered
  • Beneficiary (or designee) signature

The date delivered on the POD must be the date that the DMEPOS item was received by the beneficiary or designee. The date of delivery may be entered by the beneficiary, designee, or the supplier. When the supplier's delivery documents have both a supplier-entered date and a beneficiary or beneficiary's designee signature date on the POD document, the beneficiary (or designee) entered date is the date of service.

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.

Method 2—Delivery via Shipping or Delivery Service Directly to a Beneficiary
If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable POD would include both the supplier's own detailed shipping invoice and the delivery service's tracking information. The supplier's record must be linked to the delivery service record by some clear method like the delivery service's package identification number or supplier's invoice number for the package sent to the beneficiary. The POD document must include:

  • Beneficiary's name
  • Delivery address
  • Delivery service's package identification number, supplier invoice number, or alternative method that links the supplier's delivery documents with the delivery service's records
  • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered
  • Quantity delivered
  • Date delivered
  • Evidence of delivery

If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service on the claim.

Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This type of POD document must contain the information specified above.

Method 3—Delivery to Nursing Facility on Behalf of a Beneficiary
For items directly delivered by the supplier to a nursing facility or when a delivery service or mail order is used to deliver the item(s) to a nursing facility, the supplier must have:

  • Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and
  • Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.

Documentation does not support coverage criteria.

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

  1. Require stabilization for medical reasons, and,
  2. Have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.

Detailed Written Order (DWO) was not received.

A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

  • Beneficiary's name
  • Physician's name
  • Date of the order and the start date, if start date is different from the date of the order
  • Detailed description of the item(s) (see below for specific requirements for selected items)
  • Prescribing physician's signature
  • Signature date, if applicable (see below)

For items provided on a periodic basis, including drugs, the written order must include:

  • Item(s) to be dispensed
  • Dosage or concentration, if applicable
  • Route of Administration, if applicable
  • Frequency of use
  • Duration of infusion, if applicable
  • Quantity to be dispensed
  • Number of refills

For the "Date of the order" described above, use the dispensing order date i.e., the date the supplier was contacted by the prescribing physician (for verbal orders) or the date entered by the prescribing physician (for written dispensing orders).

Additional order date instructions:

  • If the prescriber creates the DWO, only a single date - the "order date" - is required. This order date may be the date that the prescriber signs the document.
  • If someone other than the prescriber (e.g., DME supplier) creates the DWO then the prescription must be reviewed and, "…personally signed and dated…" by the prescriber. In this scenario, two dates are required: an "order date" and a prescriber-entered "signature date".

In some cases, the prescribing physician may specify a future start date for therapy that is different from the date of the order. This start date does not impact the date of the order, DOS entered on the claim, Medicare-required forms (e.g., CMN, DIF) or refill/delivery timelines. As long as the supplier has a properly completed dispensing order with a correctly determined prescription date, an item may be shipped or delivered on or after the date of the dispensing order (except for items that require written order prior to delivery).

Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state "PRN" or "as needed" utilization estimates for replacement frequency, use, or consumption are not sufficient to justify payment.

The detailed description in the written order may be either a narrative description or a brand name/model number.

Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

 

Last Updated Jun 08, 2017