Knee 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 L1832, L1833, L1843, L1846, L1851 and L1852. The quarterly edit effectiveness results from April 2022 - June 2022 are as follows:

Based on dollars, the overall claim potential improper payment rate is 63%.

Top Medical Necessity Denial Reasons

  • The documentation does not demonstrate more than minimal self adjustment modifications were performed to the prefabricated orthosis.
  • The medical record documentation does not demonstrate an objective description of joint laxity. Refer to Local Coverage Determination L33318 and Policy Article A52465.
  • The medical record documentation does not demonstrate knee instability by examination of the beneficiary. Refer to Local Coverage Determination L33318 and Policy Article A52465.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
  • The documentation does not include a face-to-face encounter within six months prior to the order.

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 Thu, 13 Oct 2022 13:34:32 +0000