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David McGill Blogger

New Region D Prepayment Claim Review Results

Posted by David McGill | June 14, 2017

​Noridian, the DME MAC for Region D, has released the latest results from its prepayment claim review of knee orthoses (L1832, L1843). Here's what you need to know:

  • The L1832 review had a 100% claim denial rate for the 139 claims examined.
  • The L1843 review also had a 100% claim denial rate for the 117 claims examined.
  • Noridian identified 4 "top denial reasons" for these L codes:
    • Documentation does not support custom fit criteria;
    • Documentation does not support coverage criteria;
    • Suppliers failed to respond to the Additional Documentation Request; and
    • The proof of delivery form was incomplete or missing elements.

What does this mean for you?

Based on these results, Noridian will continue its prepayment claim review of knee orthoses described by these L codes. In the meantime, you can and should take the following steps to make sure your claims satisfy Medicare's requirements.

First, remember that custom-fit items involve:
(1) substantial modification
2) made by a qualified individual
(3) at the time of delivery. If you cannot demonstrate all three elements, you should not be billing the item using the custom-fit code.

Second, review the Local Coverage Determination for knee orthoses and the related Standard Documentation Requirements for All Claims Submitted to DME MACs document. You can also review our various knee orthosis checklists and reimbursement guides located in the "Reimbursement Resources" section of Össur R&R for relevant information.

Third, as we have said repeatedly in the past, you must respond to Additional Documentation Requests. Failure to do so may lead to investigation by the National Supplier Clearinghouse.

Lastly, make sure that your proof of delivery forms (a) contain all the elements required by Medicare and (b) get filled out completely before you submit your claim.

We will keep you apprised of further developments regarding Region D's prepayment claim review of knee orthoses as information becomes available in the future.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]