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 code(s) L4360, L4361, L1970 and L1940. The quarterly edit effectiveness results from July 2019 – September 2019 are as follows:

Based on dollars, the overall claim potential improper payment rate is 51%.

Top Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Claim is the same or similar to another claim on file.
  • Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.
  • Documentation does not support custom fit criteria.

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 Dec 12, 2019