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2019 Quarterly Status Report – HCPCS Code L1832, L1833

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows:

An analysis of the claim denials showed that the top 10 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. Refer to L33318. 63.01%
2 The medical record does not contain one of the diagnoses required by the LCD. Refer to L33318. 17.81%
3 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. Refer to L33318. 15.07%
4 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 13.70%
4 The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. Refer to L33318. 13.70%
6 The item was provided prior to an inpatient hospital admission or Part A covered skilled nursing facility stay and its use began during the stay. Refer to A52456. 9.59%
7 The file does not include medical records that describe a recent injury or a surgical procedure on the knee(s). Refer to L33318. 5.48%
8 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04. 4.11%
8 The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. Refer to L33318. 4.11%
10 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 2.74%

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

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