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DME MACs Issue "Dear Physician" Letter and Region D Claim Review Results for Knee Orthoses

Posted by David McGill | May 03, 2018

​The DME MACs have released a "Dear Physician" letter and Region D (Noridian) has published new claims review data, both for knee orthoses. Here's what you need to know.

1. The "Dear Physician" Letter

The letter summarizes certain elements of the Local Coverage Determination for knee orthoses, focusing on:

  1. General coverage requirements for these devices, along with a list of L codes to which the Dear Physician lettter applies; and
  2. Medical necessity requirements for different types of knee orthoses, separated by L code.
2. Noridian's Targeted Probe & Educate Results for Knee Orthoses

The TPE results for Q4 2017 include the following:
  1. The overall potential claim improper payment rate for the claims reviewed was 77%.
  2. The TPE focused on the following

    codes: L1810, L1812, L1832, L1833 and L1843. 

  3. The top reasons for denial were: (i) documentation failed to support coverage criteria; (ii) the supplier failed to respond to the Additional Docunmentation Request letter; (iii) the Detailed Written Order was incomplete or missing elements; and (iv) documentation failed to support custom-fit criteria in the LCD and Policy Article.

What does this mean for you?

First, while the Dear Physician letter and Region D TPE results are separate documents, it is hard not to see an important relationship between them. The Dear Physician letter is intended to help suppliers get the documentation they need from physicians when providing knee orthoses, and the first reason listed by Noridian for denied claims in its TPE results summary is the failure of the relevant documentation to support coverage criteria. Whether the Dear Physician letter will have the intended effect, however, is questionable. 

Physicians and their staff tend not to be intimately involved in the coding and coverage requirements for items provided by health care professionals other than themselves. So a 2+ page document centered around specific codes that physicians aren't familiar with may have a negligible effect on their behavior. Indeed, the experience of O&P professionals with the 2011 Dear Physician letter for lower limb prostheses - a letter that was shorter and less complex than the current one - suggested that few physicians even knew it existed, much less integrated its guidance into their practice. Looking at the proverbial glass as half full, however, the Dear Physician letter does at least provide you an objective document establishing that all of the things you have been asking doctors to include in their notes are not just busy work you are creating for them, but rather, actual Medicare coverage requirements that you and they are both required to follow.

Second, the other reasons for denial listed in the TPE results are easily fixable. As we have said repeatedly in the past, if you get an Additional Documentation Request letter, you must respond. Failure to respond can lead to the MACs referring you to the National Supplier Clearinghouse and the suspension of your Medicare billing privileges. Similarly, the requirements to create a valid Detailed Written Order are simple and easy to understand. Finally, the custom-fit coding criteria are spelled out in the Knee Orthoses LCD and accompanying Policy Article. If you are not familiar with one or more of these requirements, go to the LCD and Policy Article and carefully read both.

Lastly, the high claim improper payment rate of 77% suggests that knee orthoses will continue to be an area of focus for Noridian and, likely, the other DME MACs as well. The TPE process is time-consuming and has serious consequences if you cannot achieve a high enough pass rate. So make sure that your current processes for knee orthosis claims satisfy Medicare's requirements to limit your exposure moving forward.

We will keep you apprised of further developments in the knee orthosis space as they occur. 
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