Ankle-Foot Orthoses Audit Results and Top Denial Reasons

NoridianMedicare and CGSMedicare, released results of pre payment claims audits for AFOs for the period July – September 2022. The top reasons for denial include:

Denial Reason: Insufficient documentation when replacement devices are provided. 

Solution: When replacing a device, the medical documentation needs to verify the original item was lost, stolen or irreparably damaged. 

Reference: Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426.

Denial Reason: Medical records does not detail the patient is ambulatory

Solution: Check the physician’s notes for ambulatory status of patient

Reference:  Ankle-Foot Orthoses LCD

Denial Reason: Claim submitted with incorrect HCPCS or modifier. 

Solution: Refer to PDAC for correct coding of the product. Use the Modifier Search Tool to determine the correct modifiers for the HCPCS used. 

Reference: Ankle-Foot Orthoses LCD

Denial Reason: The Standard Written Order (SWO) is incomplete or invalid

Solution: Check your EMR system for all required elements on the SWO.

Reference: Standard Documentation Requirements A55426.

Jurisdiction A and D, Noridian Medicare, offers a Clinician Checklist for AFO and a Clinical Letter for AFOs. Use these resources to educate your team and referral sources.

CGS Medicare, Jurisdiction B and C, offers several on-demand webinars.

Össur offers guides and checklists for our products. You may obtain these from your Ossur representative or contact us at [email protected]