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David McGill Blogger

K3 Feet in Region D: The Trend Continues

Posted by David McGill | October 22, 2014

Region D has consistently published the results of its prepayment claim reviews for K3 feet since it began its investigation of these claims in August, 2013. In just over a year, it has issued 8 reports on K3 feet, the most recent of which Noridian posted yesterday on its website. The latest report focuses on L5980, the 4th report addressing that code in the last year. Here are the key findings:

  • Only 17% of the claims reviewed met Medicare's coverage requirements (8 of 48 claims);
  • The most common reasons for denial were
    • Documentation didn't support the claimed functional level;
    • Documentation didn't support the need for replacement;
    • Inadequate proof that the patient would reach or maintain​ the claimed functional level within a reasonable period of time;
    • Documentation didn't make clear that the patient was motivated to ambulate; and
    • Submitted documentation wasn't properly authenticated.

Based on these results, Region D announced that it would continue its prepayment review. Indeed, the 8 reports paint a repetitive, bleak picture of suppliers' ability to comply with Medicare's coverage requirements, both for K3 feet generally and L5980 feet specifically:

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What does this mean for you?

If you're in Region D, this means that Noridian will continue to closely scrutinize claims for K3 feet. Until suppliers in Region D demonstrate that they understand and satisfy Medicare's claim requirements, these prepayment claim reviews will continue. Based on the most recent data, suppliers need to focus on:

  1. Making sure both their notes and the physician's support the stated functional level;
  2. Clearly stating why the prosthesis/part of the prosthesis needs to be replaced rather than repaired;
  3. Making sure both their notes and the physician's document that the patient will reach the stated functional level within a reasonable period of time (if the patient is not yet at the stated functional level);
  4. Making sure both their notes and the physician's document that the patient is motivated to ambulate; and
  5. Confirming that their notes and the physician's are properly authenticated (e.g., signatures, dates, etc.).

For more detailed information on Medicare's claim requirements, you should review the Local Coverage Determination for Lower Limb Prostheses and the accompanying Policy Article. ​

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