The medical review department at Noridian, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released quarterly results of its Targeted Probe and Educate pre-payment reviews of AFOs, knee and spinal orthoses, and therapeutic shoes. The reviews were conducted in January through March.
Based on dollars, the overall claim potential improper payment rate for AFO Healthcare Common Procedure Coding System (HCPCS) codes L-1970, L-1971, L-4360 and L-4361 was 32 percent.
The top medical necessity denial reasons were as follows:
- Medical record documentation does not support the beneficiary has weakness or deformity of the foot and ankle.
- Medical record documentation does not support the beneficiary is ambulatory.
- Medical record documentation indicates the item is needed during post-operative recovery; however the surgery has not yet taken place.
The top technical denial reasons were:
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Claim is the same or similar to another claim on file.
- 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 rate for knee orthoses HCPCS codes L-1832, L-1833, L-1843 and L-1851 was 44 percent.
The top medical necessity denial reasons were:
- Medical record documentation does not demonstrate knee instability by examination of the beneficiary.
- Documentation does not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.
- Medical record documentation does not demonstrate knee instability due to an applicable group four diagnosis code.
Based on dollars, the overall claim potential improper payment rate for spinal orthoses HCPCS codes L-0627, L-0631, L-0637, L-0642, L-0648 and L-0650 was 24 percent.
The top medical necessity denial reasons were:
- Documentation does not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.
- Medical record documentation indicates the item is needed during post-operative recovery; however the surgery has not yet taken place.
- Medical record documentation does not demonstrate the spinal orthosis is indicated to reduce pain by restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine.
The top technical denial reasons were:
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Claim is the same or similar to another claim on file.
- 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 rate for therapeutic shoes HCPCS code A-5500 was 64 percent.
The top medical necessity denial reasons were:
- Documentation does not demonstrate an objective assessment of the fit of the shoe and inserts.
- Certifying physician has not initialed, dated, and indicated agreement with information from the medical record documentation of the in-person visit by another practitioner prior to signing the certification statement.
- Documentation does not demonstrate measurements of the beneficiary’s feet were obtained.
The top technical denial reasons were:
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- No medical record documentation was received.
- Medical record documentation was not authenticated (handwritten or electronic) by the author.
