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Linda Collins Blogger

Knee Braces, Back Braces and Region D

Posted by Linda Collins | August 06, 2014

Noridian, Region D contractor for DMEPOS, announced it would begin pre-payment probe audits on Spinal Orthoses (HCPCS L0648 and L0650) and Knee Orthoses (HCPCS L1832, L1833, and L1843.)

What exactly is a pre-payment probe audit?

After the claim is submitted, but prior to payment being made, the auditing staff at Noridian will randomly pull claims with the above-listed HCPCS codes for further review. Noridian will send an Additional Documentation Request (ADR) letter to the billing supplier and ask for copies of the dispensing order, medical records, Detailed Written Order (DWO), corroborating physician notes, and Proof of Delivery (POD.)

After review of the documentation, the auditors will either release the claim for payment or send a claims denial notification to the supplier. Based upon the error rate (how many claims are denied for payment), Noridian will make a determination if this probe audit becomes a full blown pre-payment audit, or if they close the issue.

What does this mean for you?

You and your staff should immediately review the LCDs for Spinal Orthoses (LCD 11459) and Knee Orthoses (LCD 27058), especially if you are in Region D. (Note: Region D is the only DME MAC pursuing this probe at this time, but the other three regions may follow.) You may access these policies .

Based upon the codes selected for review, it is likely Noridian will be looking for the DWO to specifically mention either an OTS or custom-fit brace. If a custom-fit brace is delivered, the notes are expected to reflect the need for a custom-fit brace, what specifically was done to the brace at time of fitting to customize it for the patient, and who fit the brace.

Further information can be found in previous posts, including 1, 2, 3 for Orthoses Claim Billing” July 15, 2014 and Code Confusion and Off the Shelf Orthotics” April 10, 2014. You may also click on Reimbursement Resources on the left hand side of this page for several resources Össur has created to assist you with claims submission.

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