Noridian Healthcare Solutions, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor, released the January-March 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 36 percent. The top denial reasons were that documentation was not received in response to the ADR letter and the claim was the same or similar to another claim on file.
Based on dollars, the overall claim potential improper payment rate for the review of knee orthosis HCPCS codes L-1832, L-1833, L-1843, and L-1851 was 48 percent. The top denial reasons were that documentation did not support coverage criteria; and the Advance Beneficiary Notice of Noncoverage (ABN) was not properly executed.
Based on dollars, the overall claim potential improper payment rate for spinal orthoses HCPCS codes L-0648 and L-0650 was 68 percent. The top denial reasons were that documentation was not received in response to the ADR letter; no medical record documentation was received; the claim is the same or similar to another claim on file; and documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.
Based on dollars, the overall claim potential improper payment for therapeutic shoes HCPCS code A-5500 rate 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.
To see the complete results of the reviews, visit Noridian’s latest updates page.
