Spinal 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) L0637. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 19%.

Top Medical Necessity Denial Reasons

  • 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 orthoses.

Top Technical Denial Reasons

  • Medical record documentation does not demonstrate a change in the patient's medical condition necessitating a different item.
  • Face-to-face encounter is not authenticated (handwritten or electronic) by the author.
  • Documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.

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 Apr 24 , 2024