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 & L4361. The quarterly edit effectiveness results from October 2022 - December 2022 are as follows:

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

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support the beneficiary is ambulatory.
  • The medical record documentation indicates the item is needed during post-operative recovery; however the surgery has not yet taken place.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Claims history indicates same or similar durable medical equipment within the last five years. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50.1.
  • The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426.

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, 18 Jan 2023 15:45:25 +0000