Noridian, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor, released the year’s first quarter (Q1) results of its targeted probe and educate pre-payment service-specific review for knee orthoses, therapeutic shoes, and AFOs.
Analysis of claim denials for knee orthoses Healthcare Common Procedure Coding System (HCPCS) codes L-1820, L-1833, and L-1852 revealed a denial rate of 51 percent. The top reasons for claim denial were that the medical record documentation did not support the beneficiary having a recent injury or a surgical procedure on the knee(s); documentation did not demonstrate knee instability by examination; and that the addition code was not reasonable and necessary. The top technical denial reasons were that documentation was not received in response to the Additional Documentation Request (ADR) letter; documentation did not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident; and that documentation did not include a standard written order (SWO).
Therapeutic shoes/inserts for diabetic persons HCPCS code A-5500 had a denial rate of 33 percent. The top reason for claim denial was that the medical record documentation did not demonstrate the beneficiary has one or more qualifying conditions; documentation was not received in response to the ADR; documentation did include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident; and documentation did not include a SWO.
Noridian reported no improper payments for AFO HCPCS codes L-4360 and L-4361.
