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(s) L1810, L1812, L1830, L1832, L1833, L1843, L1845 and L1852. The quarterly edit effectiveness results from January 2019 through March 2019 are as follows:

Based on dollars, the overall claim potential improper payment rate is 61%.

Top Denial Reasons

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Knee Orthosis Local Coverage Determination (LCD) L33318, Policy Article A52465 [PDF] and Standard Documentation Requirements Article A55426.

Suppliers can also review specific policy resources for Knee Orthosis on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, and FAQs.

Suppliers can also review a specific policy Documentation Checklist for Knee Orthosis.

Noridian provides education via supplier webinars, training opportunities, and presentations.

Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

Policy Education

Documentation does not support coverage criteria

COVERAGE CRITERIA

For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

The medical record documentation does not include Medicare approved interactive audio and video telecommunications systems to document the beneficiary's current condition

A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. (PIM 5.2.3)

An interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site is required as a condition of payment; however, BIPA does allow the use of asynchronous "store and forward" technology in delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii. BIPA does not require that a practitioner present the patient for interactive telehealth services.

Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by §332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by §1886(d)(2)(D) (go to the link and select the applicable title) of the Act.

The Health Resources and Services Administration (HRSA) determines HPSAs, and the United States (U.S.) Census Bureau determines MSAs. You can access HRSA's Medicare Telehealth Payment Eligibility Analyzer to determine a potential originating site's eligibility for Medicare telehealth payment at http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx on the HRSA website.

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Originating sites authorized by law are listed below:

  • The office of a physician or practitioner;
  • A hospital (inpatient or outpatient);
  • A critical access hospital (CAH);
  • A rural health clinic (RHC);
  • A federally qualified health center (FQHC);
  • A hospital-based or critical access hospital-based renal dialysis center (including satellites) (effective January 1, 2009);
  • A skilled nursing facility (SNF) (effective January 1, 2009); and
  • A community mental health center (CMHC) (effective January 1, 2009).

Note: Independent renal dialysis facilities are not eligible originating sites.

For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.

Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident

The definition of replacement is found in the CMS Benefit Policy Manual (Internet-only manual 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entire identical or nearly identical item when it is lost, stolen or irreparably damaged.

Beneficiary owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).

Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no cases can it be less than 5 years. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement.

 

Last Updated Jun 27, 2019