Knee Orthosis (HCPCS L1833 & L1851) Final Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes L1833 and L1851. 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 62% for HCPCS L1833.

Based on dollars, the overall claim potential improper payment rate is 88% for HCPCS L1851.

Top Denial Reasons

  • Documentation was not received in response to the Post-Payment Notification Letter.
  • Documentation does not support coverage criteria.
  • The item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual

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.


Last Updated Fri, 14 Jan 2022 13:42:45 +0000