Knee Orthoses Quarterly Results of TPE Review - JD DME

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L1820, L1843, L1845, L1846 and L1852. The quarterly edit effectiveness results from April 2024 - June 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 20%.

Top Medical Necessity Denial Reasons

• Medical record documentation does not demonstrate knee instability due to an applicable group four diagnosis code. Refer to Local Coverage Determination L33318 and Policy Article A52465.
• Documentation does not include a detailed description of the modifications necessary for the item requiring more than minimal self-adjustment by a qualified practitioner at the time of fitting the orthosis. Refer to applicable Local Coverage Determination/Policy Article.

Top Technical Denial Reasons

• N/A

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.