Noridian, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor, released quarterly results of its targeted probe and educate (TPE) review for ankle-foot, knee, and spinal orthoses, and therapeutic shoes. The reviews were conducted in January through March.
Claim denials for AFO Healthcare Common Procedure Coding System (HCPCS) codes L-1970, L-1971, L-4360, and L-4361 had a denial rate of 37 percent. The top reason for claim denial was that the medical record documentation did not support that the beneficiary requires stabilization for medical reasons.
Analysis of claim denials for knee orthoses HCPCS codes L-1843, L-1845, and L-1852 revealed a denial rate of 93 percent. The top reason for claim denial was that the medical record documentation did not demonstrate an objective description of joint laxity.
Claim denials for spinal orthosis HCPCS codes L-0627, L-0631, L-0637, and L-0642 had a denial rate of 93 percent. The top reason for claim denial was that the documentation did not demonstrate more than minimal self-adjustment modifications were performed to the prefabricated orthosis.
Therapeutic shoes/inserts for diabetic persons HCPCS codes A-5500 had a denial rate of 46 percent. The top reason for claim denial was that the medical record documentation did not demonstrate the beneficiary has one or more qualifying conditions.
