Knee Orthoses Quarterly Results of TPE Review - JD DME
Knee Orthoses 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) L1843, L1844, L1845, L1846 and L1852. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 28%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s).
- Medical record documentation does not demonstrate knee instability by examination of the beneficiary.
- Medical record documentation does not demonstrate an objective description of joint laxity.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Face-to-face encounter is greater than six months prior to the date of the standard written order (SWO) required prior to delivery.
- Medical record documentation is not authenticated (handwritten or electronic) by the author.
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.
