The medical review department at Noridian, the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor, released quarterly results of its Targeted Probe and Educate (TPE) review of AFO codes L-4360 and L-4361 covering July-September.
Based on dollars, the overall claim potential improper payment rate was 25 percent.
The top medical necessity denial reasons were that the medical record documentation did not support that the beneficiary is ambulatory; the medical record documentation did not indicate medical necessity for the item at the time of delivery; and the documentation did not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.
The top technical denial reasons were that documentation was not received in response to the Additional Documentation Request letter; the claim was submitted with an incorrect modifier; and the item was provided during an inpatient hospital or Part A covered skilled nursing facility stay prior to the day of discharge and the use began during the stay.
