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September 9, 2020

Widespread Post-Pay Service Specific Review Announcement – HCPCS Codes L1833 and L1851

CGS's Medical Review staff will be conducting a complex post-pay service-specific medical review of HCPCS Code (S) L1833 and L1851 (Knee orthosis) claims. This review will be conducted because data analysis revealed that Jurisdiction B's allowed dollars for HCPCS Code L1833, and L1851 were significantly above expected amounts. Additionally, the Knee Orthosis policy group ranked #9 in total CERT errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6).  Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order);
  2. A valid order;
  3. Any medical records from the place of services rendered, physician history and progress notes, diagnoses/conditions, physicals, diagnostic testing (including MRI, CT results, etc.), lab tests and any other pertinent information to document the medical necessity of the orthoses chosen. Provide documentation to substantiate the choice of custom made over prefabricated, if applicable. Include CPO documentation regarding evaluation, and fitting if applicable, signed and dated legibly;
  4. Non-physician clinical assessments and progress notes from nurses, physical therapists, occupational therapists, and ancillary services;
  5. Copies of supplier's records for dates of direct patient contact related to the evaluation, fitting, and delivery of the orthosis;
  6. Manufacturer's name and model name & number of the items provided. Include information about the fabrication of any item submitted if it is considered custom;
  7. If the patient has or had same/similar items, documentation indicating the reason new equipment/item(s) is medically necessary;
  8. Copy of an Advance Beneficiary Notice (ABN), if one was obtained.
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