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Linda Collins Blogger

RAC Audit Issues

Posted by Linda Collins | May 15, 2018

Performant Recovery, the recovery auditor for DMEPOS, has identified several areas for audit which impact the O&P practice.

Spinal Orthoses

Medical record documentation must support medical necessity. Affected Codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.

Medical Necessity KAFO/AFO

Ankle-Foot Orthosis and Knee-Ankle-Foot Orthosis must meet basic coverage criteria. Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.

DMEPOS Billed While Inpatient

DMEPOS items delivered inpatient is subject to the 48-hour rule. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.

 CPM Billed without TKR

Automated CPM Billed without Total Knee Replacement

What Does This Mean for You?

The Recovery Auditor may request review of claims for the past three years. If you do get an audit request, be sure to provide all the medical record documentation, the prescriptions,  and the delivery ticket.


Proactively, review the Local Coverage Determinations (LCDs) associated with the targeted items. You may also download several resources and guides under the "Reimbursement Resources" section of this R&R.


You may learn more about each of the audit issues here

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]