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) L0456, L0457, L0627, L0631, L0637, L0642, L0648 and L0650. The quarterly edit effectiveness results from January 1, 2020 to March 31, 2020 are as follows:

Based on dollars, the overall claim potential improper payment rate is 30%.

Top Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Medical record documentation was not received.
  • Medical record documentation was not authenticated (handwritten or electronic) by the auther.
  • Documentation does not support coverage criteria.

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 Mon, 04 May 2020 17:37:49 +0000