Targeted Probe and Education (TPE) Audit Results: AFOs

DME MAC, D, Noridian released results of the TPE audits for Ankle-Foot-Orthoses for April - June, 2022.

Targeted Probe and Education (TPE) audits are focused on suppliers who have a high claim error rate for specific HCPCS codes. Initially, the supplier is contacted and provided with information about the reasons for denials. The supplier then has the chance to work directly with the auditor as claims are reviewed. The purpose is to provide immediate and relevant feedback to the supplier. After education, there is another audit of the claims. If there is significant improvement, the audit is closed.

The AFO results are worth sharing so all suppliers can learn and prevent future audits. According to the recent findings, the top three reasons for medical necessity denial on AFO claims are:

• AFO provided pre surgery, but documentation does not justify need prior to surgery.
   
• Documentation does not support the patient is ambulatory
   
• General medical necessity requirements are not documented at time of delivery.

What Does This Mean for You?

Make sure you and your staff are familiar with the medical necessity requirements for AFOs. This medical necessity criteria must be documented on the date of delivery:

• Patient is ambulatory; and
• Has a weakness or deformity of the foot and ankle; and 
• Requires stabilization of the foot and ankle for medical reasons; and
• Has the potential to benefit functionally from the use of an AFO

Jurisdiction D provides resources for you, including checklists and links to the LCD – view here. The criteria in these resources is appropriate for all jurisdictions.

Ask your Össur representative for the summaries and guides we have created for you. Or log into our Reimbursement Resource Center here and download the guides.

You can learn more about TPE Audits here.