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Linda Collins Blogger

New Pre-Payment Probes for L1940 and L4360

Posted by Linda Collins | May 21, 2015

NHIC, Region A, Medicare Administrative Contractor has announced new prepayment probes for AFOs billed with L1940 and Pneumatic Walkers billed with L4360.

What is a prepayment probe?

The MAC may initiate a probe into claims paid under a specific code if there is a high number of claim errors identified by the CERT contractor. During the probe, the claims identified for review will be compared to the criteria outlined in the associated Local Coverage Decision (LCD.)  The results of the probe are published and if the outcome shows a high percentage of inappropriately paid claims, the probe may turn into a full audit.

What does this mean for you?

Review Local Coverage Determination (LCD) for Ankle-Foot/Knee-Ankle-Foot Orthosis (L11527.)

L1940, a custom-fabricated AFO, requires additional documentation in the medical records to support the medical necessity of the product. In general, an AFO is covered if there is documentation indicating the beneficiary:

  1. Requires stabilization for medical reasons, and,
  2. Has the potential to benefit functionally.

Custom AFOs may be covered when the following additional criteria is also present:

  1. The beneficiary could not be fit with a prefabricated AFO; or,
  2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
  3. There is a need to control the knee, ankle or foot in more than one plane; or,
  4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
  5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

The above criteria will need to be in the clinician’s notes and corroborated in the physician’s notes.

A pneumatic walking boot, L4360, is also covered for a beneficiary if there is a documented need for stabilization AND the beneficiary has the potential to benefit functionally. This AFO is a custom-fit code and requires documentation detailing the modifications done to the brace at time of fitting. (See The OTS/Custom-Fit Difference)

If your claim is selected for review as part of the pre-payment probe, you will receive an Additional Documentation Request letter. Be sure to gather all your notes and supporting documents and respond to the request within the 45-day time frame. 

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