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Linda Collins Blogger

Ankle and Knee Brace Audits

Posted by Linda Collins | March 24, 2017

Noridian, Jurisdiction D, DME MAC, is continuing audits on specific AFO and KO HCPCS codes. They recently published results of the fourth quarter 2016 audits.

Ankle-Foot Orthosis, L4361

The results of this audit showed the top reasons for denial to be:

  • No Detailed Written Order (DWO)
  • No Proof of Delivery (POD)
  • Same or Similar claim on file
  • Documentation does not support medical necessity criteria

Knee Orthosis, L1832, L1843

The top denial reasons for this audit were:

  • No Proof of Delivery (POD)
  • Documentation does not support medical necessity criteria
  • No response to the request for documentation
  • Documentation does not support custom fit criteria

​Reminders:

A Detailed Written Orders (DWO) is required before billing. The ordering physician must sign and date the order.  DWO requirements are detailed here.

All suppliers are required to have a signed and dated POD from each patient receiving services. The POD must be kept on file and available for review by auditors. More information about PODs is found here.

A same or similar denial may occur when the patient has received a same or similar device, within the defined lifetime of the brace, to the one being billed. Medicare suggests the standard patient intake form ask about previous device use.

The LCDs for AFOs and KOs list the medical necessity requirements for each brace type. The physician's documentation and the supplier's documentation must corroborate these requirements. Review the LCDs and download the Össur Reimbursement Guides.

Knee Braces billed with HCPCS L1843 must have objective documentation of knee instability. The Össur OA Knee Brace Checklist is a helpful guide.

If a custom-fit brace is distributed, the supplier's documentation must detail the substantial modifications made to the brace, the reason for the modifications, and the person performing the work. If there are not substantial modifications being made, the Off the Shelf code for the brace should be utilized. In this case, L1843 is a custom-fit brace, which requires the extensive documentation. The off the shelf code is L1851. This code should be used when the brace requires only minor adjustments at the time of fitting. More information on these requirements are listed in the Knee Orthosis LCD.

What does this mean for you?

Review the documentation and paperwork requirements, check the LCDs for the medical necessity requirements, and respond to requests for documentation review.

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