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Linda Collins Blogger

Ankle Brace Documentation Requirements

Posted by Linda Collins | December 11, 2014

MAC Region D (Nordian) recently announced the results of a pre-payment audit for HCPCS codes L1960, L1970 and L4360 for claims submitted between June 2014 - September 2014. The claim denial rate for these codes, respectively, was 89%, 87% and 83%.

Noridian cites the following top denial reasons:

  • lack of detailed documentation to support medical necessity
  • missing medical records to support the need for a custom brace, and
  • no proof of delivery.

What can you do to prevent your claims from failing a review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Remember the three key requirements.

1. Detailed Written Order

CMS requires you to obtain a detailed written order on all items . 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. 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
  • Detailed description of the item(s)
  • Physician signature and signature date

**When a custom fabricated orthosis is ordered, this must be clearly indicated on the DWO.


2. Medical Coverage Criteria Documentation

Medicare expects that the beneficiary's medical records will reflect the need for the care provided. This documentation must be available upon request.

In the case of custom-fabricated AFOs, additional documentation is required. The LCD states that for a custom-fabricated orthosis, the patient must meet one of the following criteria, and the medical record must specifically document it:

  • 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 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 that lacks normal anatomic integrity or anthropometric proportions.

*This information must be corroborated in the physician’s medical records.

3. Proof of Delivery

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

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