Noridian, the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) is conducting Targeted Probe and Educate (TPE) reviews for several specialties, among which are ankle-foot orthoses (AFOs), knee orthoses, and therapeutic shoes. The quarterly edit effectiveness results from October 2019 through December 2019 indicate the following:
- AFOs: The affected Healthcare Common Procedure Coding System (HCPCS) codes are L1940, L1971, L4360, and L4361. Based on dollars, the overall claim potential improper payment rate is 31%.
- Knee orthoses: The affected HCPCS codes are L1810, L1812, L1832, L1833, L1843, L1844, and L1851. Based on dollars, the overall claim potential improper payment rate is 45%.
- Therapeutic shoes: The affected HCPCS code is A5500. Based on dollars, the overall claim potential improper payment rate is 52%.
The top denial reasons include documentation was not received in response to the Additional Documentation Request (ADR) letter; documentation does not support coverage criteria; and the claim is the same or similar to another claim on file.
For more information, visit med.noridianmedicare.com/web/jddme/cert-review/mr/review-results.