On August 7, 2018, the Centers for Medicare & Medicaid Services published two new proposed issues for review by Performant Recovery, the Recovery Audit Contractor (RAC) for durable medical equipment prosthetics, orthotics, and supplies (DMEPOS); home health; and hospice claims nationwide. The two issues that have been proposed for RAC review are a review of custom fabricated knee orthoses described by Healthcare Common Procedure Coding System (HCPCS) code L1844 (KO w/adj jt rot cntrl molded) and L1846 (KO w adj flex/ext rotat mold), and a review of durable medical equipment (DME) services billed to a Medicare beneficiary during a hospice stay.
The proposed RAC review of L1844 and L846 is a complex review; claims for custom-fabricated knee orthoses submitted on or after October 1, 2015, that do not meet indications of coverage and/or medical necessity outlined in the references listed in the announcement will be denied.
The second proposed RAC review is an automated review. All DME billed during a Medicare-covered hospice stay will be denied as inclusive to hospice services unless there is a GW (service unrelated to term co) modifier present indicating otherwise. The service dates under this review cover claims less than three years prior to the Initial Finding Letter date.