Noridian Healthcare Solutions, the Jurisdiction A and Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the July-September 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, 39 percent; Jurisdiction D, 34 percent.
·       KOs: Jurisdiction A, 79 percent; Jurisdiction D, 61 percent.
·       Spinal orthoses: Jurisdiction A, 25 percent; Jurisdiction D, 51 percent.
·       Therapeutic shoes: Jurisdiction A, 45 percent; Jurisdiction D, 36 percent.
The most common reason for denial was that documentation was not received in response to the Additional Documentation Request (ADR) letter.
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