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Spinal Orthosis Quarterly Results of TPE Review - JD DME

Spinal 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 L0637. The quarterly edit effectiveness results from April 2023 - June 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 42%.

Top Medical Necessity Denial Reasons

  • The documentation does not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.
  • The medical record documentation indicates the item is needed during post-operative recovery; however, the surgery has not yet taken place. Refer to Medicare Benefit Policy Manual Chapter 15, Section 110.1, Section C.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The documentation does not include a face-to-face encounter within six months prior to the order. Refer to 42 Code of Federal Regulations 410.38 (c) and Standard Documentation Requirements A55426.
  • The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.

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 Wed, 09 Aug 2023 14:31:51 +0000