Ankle-Foot Orthosis (AFO) Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes L4360 and L4361. The quarterly edit effectiveness results from July 2022 - September 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 25%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support the beneficiary is ambulatory.
  • The medical record documentation does not indicate medical necessity for the item at the time of delivery.
  • The documentation does not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The claim was submitted with an incorrect modifier. Refer to Medicare Claims Processing Manual 100-04, Chapter 20 & LCDs.
  • The item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.

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.


Last Updated Wed, 02 Nov 2022 19:36:00 +0000