The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes L1940, L1970 and L4361. The final edit effectiveness results from September 2021 through November 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 49% for HCPCS L1940.

Based on dollars, the overall claim potential improper payment rate is 52% for HCPCS L1970.

Based on dollars, the overall claim potential improper payment rate is 37% for HCPCS L4361.

Top Denial Reasons

• Documentation does not support coverage criteria.
• Documentation was not received in response to the Post-Payment Notification 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.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics webpage to access coverage documents.

• National Coverage Determination (NCD)
• Local Coverage Determination (LCD)
• Policy Article
• Documentation letters, forms, and checklists
• Review tips, tools, and resources
• Related articles
• Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.