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David McGill Blogger

A Painful Probe in Region D

Posted by David McGill | October 23, 2013

The History

MAC Region D has continued zeroing in on prosthetic feet as an area of review. We first identified this issue 9 months ago (Check Your Feet, Jan. 28, 2013 post). At that time, we warned people in Region D that they would start receiving Additional Documentation Request letters for claims involving L5980, L5981, and L5987. We even listed the items that Region D would ask about:

  • Treating MD's dispensing and written order;
  • Medical records supporting medical necessity (including physician records); and
  • Functional level justification.

Just last month, Region D announcing that it was converting its prepayment "probe review" into a full-blown, widespread prepayment review of L5981 feet - a topic we posted about on September 24 (They're Looking at Your Feet!)​.

The New Findings

Just as it did with L5981 feet, Region D has now decided to initiate a widespread prepayment review of L5980 claims. Region D made its decision based upon the following facts:

  1. 80% of the L5980 claims it reviewed failed to meet Medicare's claim requirements;
  2. Some suppliers simply failed to respond to the MAC's Additional Documentation Request Letter altogether;
  3. Some claims failed to contain adequate justification for replacement of the prosthetic foot;
  4. Some claims lacked documentation supporting the selected functional level; and
  5. Some claims lacked documentation showing that the patient would reach or maintain a defined functional state within a reasonable period of time.

​What does this mean for you?

First - and we sound like a broken record on the point - you have to know and satisfy all of the terms of the Medicare Local Coverage Determination for Lower Limb Prostheses. The issues identified by Region D are basic LCD requirements. If you don't know where to begin with the LCD, review our 4-part series beginning on August 14 of this year.

Second, despite the fact that MAC Region D publicly identified exactly what it planed to target - down to the codes at issue and the specific Medicare requirements it would examine - back in January, claim failure rates continue to hover in the 80% range. We believe it likely that the third of the 3 codes discussed in our January post on this subject - L5987 - will end up receiving similar treatment from Region D in the coming weeks or months.

Finally, make sure that you code your K3 feet accurately! Ossur has multiple K3 feet for which the PDAC has issued coding verifications:

  • Re-Flex Shock (L5987)
  • Re-Flex Rotate (L5987 + L5984)
  • Vari-Flex XC (L5981)
  • Re-Flex Modular (L5980)
  • Flex Foot Balance (L5979), and
  • PROPRIO FOOT (L5973).

The trend in Region D is clear: prepayment probe reviews with claim failure rates in the 80% range evolve into full-blown widespread prepayment reviews. Until suppliers can demonstrate compliance with the LCD's requirements and those failure rates drop significantly, we can expect the scrutiny to continue.

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com