Noridian Healthcare Solutions, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor, released the April-June results of the Targeted Probe and Educate (TPE) reviews for AFO/KAFOs, KOs, spinal orthoses, and therapeutic shoes.
Based on dollars, the overall claim potential improper payment rate for AFO/KAFO Healthcare Common Procedure Coding System (HCPCS) codes L-4360, L-4361, L-4386, and L-4387 was 51 percent. The top denial reasons were that documentation was not received in response to the Additional Documentation Request (ADR) letter and that the claim was the same or similar to another claim on file. The potential improper payment rate last quarter was 36 percent.
Based on dollars, the overall claim potential improper payment rate for the review of knee orthosis HCPCS codes L-1810, L-1812, L-1832, L-1833, L-1843, L-1851, and L-1852 was 54 percent. The top denial reasons were that documentation did not support coverage criteria and that documentation was not received in response to the ADR letter. The potential improper payment rate last quarter was 48 percent.
Based on dollars, the overall claim potential improper payment rate for spinal orthoses HCPCS codes L-0625, L-0626, L-0627, L-0630, L-0631, L-0637, L-0641, L-0642, L-0643, L-0648, and L-0650 was 60 percent. The top denial reasons were that the claim is the same or similar to another claim on file and that documentation was not received in response to the ADR letter. The potential improper payment rate last quarter was 68 percent.
Based on dollars, the overall claim potential improper payment for therapeutic shoes HCPCS code A-5500 rate was 49 percent. The top denial reasons were that documentation was not received in response to the ADR letter and that documentation did not support coverage criteria. The potential improper payment rate last quarter was 54 percent.
To see the complete results of the reviews, visit Noridian’s latest updates page.
