CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC), will begin conducting a medical record prepay, service-specific review of claims that contain the K-1007 Healthcare Common Procedure Coding System (HCPCS) code.
K-1007 is: Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors.
CGS reminded suppliers of the importance of responding to additional documentation request (ADR) letters. Federal Law at SSA 1833 (e) and Federal regulation at 42 CFR 424.5(a)(6) authorize the collection of this information. Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to the Medicare contractor. The consequences of failure to provide records may not only be a claim denial, but also referral to the National Supplier Clearinghouse.
The ADR letter will contain the following information:
- Treating practitioner’s written order
- Beneficiary’s medical records (which may include practitioner medical records, hospital records, nursing home records, home care nursing notes, and physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary, including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.
- Documentation to support the Standard Documentation Requirements for All Claims Submitted to DME MACs (Policy Article A55426)
- Any other pertinent documentation
- Copy of the Advance Beneficiary Notice, if one was obtained
Jurisdiction C includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, and West Virginia.
