CGS Administrators, LLC

Serving the states of MN, WI, IL, IN, OH, KY and MI

November 5, 2018

Status Report for Quarter 2 – 2018: HCPCS Code L1833, L1832

A summary report for claims reviewed between April 1, 2018 and June 30, 2018 follows:

An analysis of the claim denials showed that the top reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. 100.0%
2 The medical record does not contain one of the diagnoses required by the LCD. 66.67%
3 The file does not include medical records that describe a recent injury or a surgical procedure on the knee(s). 33.33%
3 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 33.33%
5 The detailed written order is missing a description of the item. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 16.67%
5 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04 16.67%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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