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David McGill Blogger

MAC Region D Release Spinal Orthoses TPE Results

Posted by David McGill | May 09, 2018

Noridian, the DME MAC for Region D, has released Targeted Probe and Educate results for spinal orthoses claims reviewed in Q4, 2017. Here's what you need to know:

  1. The TPE review focused on the following codes describing spinal orthoses: L0627, L0630, L0631, L0637, L0642, L0643, L0648 and L0650.
  2. The 8 L codes reviewed consist of 4 off-the-shelf spinal orthoses and their related custom-fit counterparts.
  3. The overall claim potential improper payment rate for these codes was 34%.
  4. The most common reasons for denial were (i) claim is the same/similar to one already on file, (ii) documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident, (iii) documentation does not support coverage criteria, and (4) documentation was not received in response to an Additional Documentation Request letter.

What does this mean for you?

With a potential improper payment rate of over one-third, we can expect Noridian (and potentially the other DME MACs as well) to continue to use the Targeted Probe and Educate review process to analyze spinal orthosis claims. Based on these results, you can do four things to minimize your company's risk in the event of a TPE review for these kinds of claims.

First, make sure to use your DME MACs online tool to verify whether and when a "same or similar" device has been provided to your patient. Regular use of this resource can help prevent unexpected denials.

Second, you must provide specific documentation verifying if equipment was lost, stolen or irreparably damaged in a specific incident. General assertions, without more, are unlikely to satisfy this requirement. 

Third, review the Local Coverage Determination for spinal orthoses and make sure that your internal claim processes include capturing all of the coverage criteria set forth in that document. The TPE review process includes a detailed analysis of whether your supporting claim materials satisfy all of the LCD's requirements. 

And finally - we have said this more times than we can count over the last few years - always respond to an ADR. Even if you review your claim and determine that you have no information responsive to the Additional Documentation Request, you should still reply to the DME MAC saying just that. Failure to respond to the ADR can result in referral to the National Supplier Clearinghouse and potential revocation of your Medicare billing privileges.

The TPE review process now appears to have displaced prepayment claim reviews as the favored approach by the DME MACs. If you fail to achieve a high enough pass rate by the end of the third round of the TPE process, the DME MACs can extrapolate to reclaim a percentage of all claims for the involved codes going back in time or, alternatively, refer you to Medicare. Therefore, having strong claim processes in place so that you can (a) pass the TPE review process, and (b) therefore avoid DME MAC TPE review of claims involving those codes for the following 12 months is critical.

We will keep you apprised of future DME MAC TPE review results as they become available. 


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