Noridian Releases Quarterly TPE Results

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Noridian Healthcare Solutions, the Jurisdiction A and Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the October-December 2018 quarterly edit effectiveness results from its Targeted Probe and Educate (TPE) reviews for AFO/KAFOs, KOs, spinal orthoses, and therapeutic shoes.

For Jurisdiction A, Noridian's Medical Review Department is conducting TPE reviews of the following Healthcare Common Procedure Coding System (HCPCS) codes:

·        AFO/KAFOs: L-1970, L-4360, and L-4361

·        KOs: L-1832, L-1833, L-1843, and L-1851

·        Spinal orthoses: L-0648, and L-0650

·        Therapeutic shoes: A-5500

For Jurisdiction D, TPE reviews are being conducted for the following HCPCS codes:

·        AFO/KAFOs: L-4360, L-4361, L-4386, and L-4387

·        KOs: L-1810, L-1812, L-1830, L-1832, L-1833, L-1843, L-1845, and L-1852

·        Spinal orthoses: L-0625, L-0626, L-0627, L-0630, L-0631, L-0637, L-0641, L-0642, L-0643, L-0648, and L-0650

·        Therapeutic shoes: A-5500

Based on dollars, the overall claim potential improper payment rates are as follows:

·        AFO/KAFOs: Jurisdiction A, 48 percent; Jurisdiction D, 34 percent.

·        KOs: Jurisdiction A, 40 percent, Jurisdiction D, 61 percent.

·        Spinal orthoses: Jurisdiction A, 29 percent; Jurisdiction D, 47 percent.

·        Therapeutic shoes: Jurisdiction A, 43 percent; Jurisdiction D, 28 percent.

The most common reason for denial was that documentation was not received in response to the Additional Documentation Request (ADR) letter. Other top reasons for denial were documentation does not support custom fit criteria, documentation does not support coverage criteria, claim is the same or similar to another claim on file, and that documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.

For complete details for the Jurisdiction A results, visit the fee schedule on the Noridian website.

For complete details for the Jurisdiction D results, visit the fee schedule on the Noridian website.