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

Based on dollars, the overall claim potential improper payment rate is 56% for HCPCS L1940.

Based on dollars, the overall claim potential improper payment rate is 53% for HCPCS L1970.

Based on dollars, the overall claim potential improper payment rate is 54% for HCPCS L4361.

Top Denial Reasons

• Documentation was not received in response to the Post-Payment Notification Letter.
• Documentation does not support coverage criteria.
• No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.
• Detailed Written Order (DWO) was not received.
• The medical record documentation is dated after the date of service. Refer to A55426.

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.