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Linda Collins Blogger

A Few Steps to Assist in AFO Claims Submission

Posted by Linda Collins | December 19, 2012

Last week the Jurisdiction D DME MAC Medical Review Department announced the results of a Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthoses (HCPCS L4360, L1970 and L1960) claims. It revealed a high percentage of claims errors due to lack of sufficient documentation, no written or verbal order, and/or no proof of delivery. As a result of the high error rate, the DME MAC will continue to review AFO claims.

So, what can you do to prevent your claims from failing a MAC review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Here is a summary of the three key requirements:

Detailed Written Order

CMS requires you to obtain a detailed written order on all items before dispensing them to patients. The treating physician must sign and date an order for each new or full replacement item billed, the supplier must keep it on file, and it must be made available upon request. For items provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

  • Beneficiary's name
  • Physician's name
  • Date of the order and start date, if start date different than date of order
  • Detailed description of the item(s)
  • Physician signature and signature date

Medical Coverage Criteria Documentation

Medicare expects that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

In the case of L1970 and L1960, which are custom fabricated AFOs, additional documentation is required. The LCD states that for a custom-fabricated orthosis to be eligible for coverage the patient must meet one of the following criteria, and this criterion must be detailed in the medical record:

  • The beneficiary could not be fit with a prefabricated AFO; or
  • The condition necessitating the orthotic is expected to be permanent or of longstanding duration (more than 6 months); or,
  • There is a need to control the knee, ankle or foot in more than one plane; or
  • The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
  • The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.

Proof of Delivery

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

The full report on the review is available here

Following a few clearly defined requirements will mean that your claims are more likely to pass reviews and audits, which means quicker payment for you. Put your best foot forward and implement these procedures in your practice today.

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