Noridian Healthcare Solutions, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the quarterly edit effectiveness results from April through June for knee, ankle-foot, and spinal orthoses. Noridian’s Medical Review Department is conducting Targeted Probe and Educate (TPE) reviews of knee orthosis Healthcare Common Procedure Coding System (HCPCS) codes L-1832, L-1833, L-1843 and L-1851; AFO HCPCS codes L-1970, L-4360 and L-4361; and spinal orthosis HCPCS codes L-0648 and L-06500.
Based on dollars, the overall claim potential improper payment rate for the knee orthosis codes was 80 percent. The top denial reasons were that documentation did not support coverage criteria, and that documentation was not received in response to the Additional Documentation Request (ADR) letter.
For the AFO codes, based on dollars, the overall claim potential improper payment rate was 39 percent. The top denial reasons were that documentation was not received in response to the ADR letter, the claim was the same or similar to another claim on file, documentation did not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident, and that documentation did not support coverage criteria.
Based on dollars, the overall claim potential improper payment rate for the spinal orthosis codes was 49 percent.
The top denial reasons were that documentation was not received in response to the ADR letter, the claim is the same or similar to another claim on file, the documentation did not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident, and that documentation did not support coverage criteria.
To see the complete results of the reviews, visit the Noridian website at Knee Orthoses Quarterly Results of Targeted Probe and Educate Review, the Ankle-Foot Orthosis Quarterly Results of Targeted Probe and Educate Review, and the Spinal Orthoses Quarterly Results of Targeted Probe and Educate Review.
