Ankle-Foot/Knee-Ankle-Foot Orthosis 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 L1940, L1971, L4360 and L4361. The quarterly edit effectiveness results from October 1, 2019 - December 31, 2019 are as follows:

Based on dollars, the overall claim potential improper payment rate is 31%.

Top Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Documentation does not support coverage criteria.
  • Claim is the same or similar to another claim on file.

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 Feb 11, 2020