Skip to Main Content

Print | Bookmark | | Font Size: + |

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)External Website. 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:

Updated: November 1, 2024

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved