LEEDer Group Inc.
156 Reasor St. #108
Oklahoma, OK 74464 USA

Phone: 305.436.5030
Fax: 305.436.0086
Email Address: email info jcr_safe_email_at_this_domain

Knee Orthoses Quarterly Results of Targeted Probe and Educate Review





Knee Orthoses Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L1832, L1833, L1843, and L1851. The quarterly edit effectiveness results from April 2019 – June 2019 are as follows:

Based on dollars, the overall claim potential improper payment rate is 62%.

Top Denial Reasons:
  • Documentation was not received in response to the Additional Documentation Request (ADR) letter
  • Documentation does not support coverage criteria
  • Advance Beneficiary Notice of Noncoverage (ABN) was not properly executed
  • Documentation does not support custom fit 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 This link will take you to an external website. information about probe/error validation reviews.

Policy Education

Documentation was not received in response to the ADR letter

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57©.

Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian’s website.

Documentation does not support 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.

ABN was not properly executed
The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case.

Since March 1, 2009, the ABN-G and ABN-L are no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131).

An ABN can remain effective for up to one year. If there is any change in care from what is described on the ABN within the 1-year period, a new ABN must be given. If during the course of treatment additional noncovered items or services are needed, the notifier must give the beneficiary another ABN. There is a one year limit for using a single ABN for an extended course of treatment. A new ABN is required when the specified treatment extends beyond one year.

The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain the original notice on file.

ABN delivery is considered to be effective when the notice is:

Delivered by a suitable notifier to a capable recipient and comprehended by that recipient.
Provided using the correct OMB approved notice with all required blanks completed.
The ABN form and instructions can be found on the ABN page.

Documentation does not support custom fit criteria
Custom fitted orthotics are:
  • Devices that are prefabricated
  • They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
  • Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
  • This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.
    Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.

Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.

Claims for custom fitted orthoses
  • (L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0626, L0627, L0630, L0631, L0633, L0635, L0637 and L0639) will be denied as incorrect coding, with a statutory denial, when documentation shows that only minimal self-adjustment was required at the time of fitting (see Policy Specific Documentation Requirements section in the Local Coverage Determination).

Last Updated Oct 22, 2019