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 April 2023 - June 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 27%.

Top Medical Necessity Denial Reasons

• The medical record documentation does not support the beneficiary is ambulatory.
• The medical record documentation does not support the beneficiary requires stabilization for medical reasons.

Top Technical Denial Reasons

• The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.

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.