Durable Medical Equipment Medicare Administrative Contractor CGS released the Jurisdiction B medical review reports and the exclusion results of the Targeted Probe and Educate (TPE) program for July through September.
Results of the TPE program were:
- Ten claim pilot success: 39 percent passed
- Round 1: 69 percent achieved exclusion
- Round 2: 59 percent achieved exclusion
- Round 3: 94 percent achieved exclusion
Claim denials for AFO Healthcare Common Procedure Coding System (HCPCS) codes L-1900-L-1990, L-2000, L-2005, L-2010-L-2136, L-4350-L-4387, L-4396-L4397, L-4631 had an error rate of 24.19 percent. The top denial reason was that the medical records received lacked sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
Knee orthoses HCPCS codes L-1832-L-1845, L-1851, L-1852, L-had an error rate of 52.54 percent. The top denial reason was that the file did not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner.
Claim denials for spinal orthosis HCPCS codes L-0450-L-0651 had an error rate of 59.86 percent. The top reason for claim denial was that the medical records did not support one of the four criteria for a spinal orthosis.
Therapeutic shoes/inserts for diabetic persons HCPCS codes A-5500, A-5512, and A-5513 had a denial rate of 54.11 percent. The top reason for claim denial was that the medical record documentation did not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there was no verification that the beneficiary had one of the six conditions the [Local Coverage Determination] specifies must be present for coverage.
