Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L4360, L4361, L4386 and L4387) Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a targeted probe and educate reviews of HCPCS code(s) L4360, L4361, L4386 and L4387. The quarterly edit effectiveness results from October 2017 through December 2017 are as follows:

Based on dollars, the overall claim potential improper payment rate is 19%.

Top Denial Reasons

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.

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.

Policy Education

Detailed Written Order (DWO) is incomplete or missing elements

A detailed written order (DWO) is required before billing. Someone other than the physician may complete the DWO of the item unless statute, manual instructions, the contractor's LCD or policy articles specify otherwise. However, the prescribing physician must review the content and sign and date the document. It must contain:

  • Beneficiary's name
  • Prescribing physician's name
  • Date of the order
  • All items, options or additional features that are separately billed or require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code narrative, or a brand name/model number
  • 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.

Medical record documentation was not authenticated (handwritten or electronic) by the author

For medical review purposes, Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies. For example, if the physician's authenticated documentation corroborates the nurse's unsigned note, and the physician was the responsible party per Medicare's payment policy, medical reviewers would consider signature requirements to have been met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.

Claim is the same or similar to another claim on file

Same or similar denials occur when the patient's CMN history indicates a piece of equipment is the same or similar to the equipment being billed.

To determine whether same or similar items have previously been provided, suppliers must obtain all possible information from a patient, which may include the following:

  • Patient's correct Health Insurance Claim number;
  • Whether the patient has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
  • If the patient currently has or had an identical or similar item in the past;
  • When the patient received the items and whether or not the items have been returned;
  • Where the item will be used; and
  • CMN or DIF information, if required.

By using the Suggested Intake Form, it assures this information is obtained. This form is available on our website under the Forms section and it contains beneficiary information, ordering physician information and questions for the beneficiary and the supplier. Suppliers can customize their own intake form to meet their needs as well.

The Noridian Medicare Portal or Interactive Voice Response System can be used to verify that a beneficiary has not had a same or similar item within the previous five years. Follow the steps listed under the manual on the Noridian Medicare Portal to check for same or similar items.

Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident

The definition of replacement is found in the CMS Benefit Policy Manual (Internet-only manual 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entire identical or nearly identical item when it is lost, stolen or irreparably damaged.

Beneficiary owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).

Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no cases can it be less than 5 years. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement.

 

Last Updated Apr 27, 2018