Knee Orthoses Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for knee orthoses HCPCS codes L1832, L1843, L1844, L1845, L1851, L1852, and L2397 reviewed July 1 – September 30, 2024. The error rate for this quarter is 49.40%. The top 9 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (for example joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. | 48.21% |
2. | The medical record does not have one of the diagnoses required by the LCD. | 21.43% |
3. | The documentation does not include a valid face-to-face encounter that meets the requirements in Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 10.71% |
4. | The documentation is incomplete. | 5.36% |
5. | We did not receive any medical record documentation. | 3.57% |
6. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 3.57% |
7. | The documentation does not have a valid written order prior to delivery. | 3.57% |
8. | The documentation does not have a valid written order. | 1.79% |
9. | The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knees. | 1.79% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Knee Orthoses Documentation Checklist
- Knee Orthoses – LCD (L33318)
- Knee Orthoses – Policy Article (A52465)
- Orthotics and Prosthetics Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: November 1, 2024