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 45.56 %. 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, or varus test) from the treating practitioner. | 55.00% |
2. | The HCPCS procedure code on the claim is not correct for the item billed. | 13.75% |
3. | The medical record does not have one of the diagnoses required by the LCD. | 10.00% |
4. | The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. | 8.75% |
5. | Documentation provided in the supplier’s records and the treating practitioner’s medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis. | 5.00% |
6. | No medical record documentation was received. | 3.75% |
7. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. | 1.25% |
8. | The file does not include medical records that support that the beneficiary is ambulatory. | 1.25% |
9. | The file does not have a valid Advance Beneficiary Notice. | 1.25% |
*The total percentage will be greater than 100% because some claims 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 5, 2024