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David McGill Blogger

Region D Knee Orthosis and Ankle-Foot Orthosis Prepayment Claim Review Results

Posted by David McGill | May 23, 2017

​The DME MAC for Region D, Noridian, has released the most recent prepayment claim review results for knee orthoses (L1833) and ankle-foot orthoses (L1960, L1970, L4360). Here's what you need to know:

Knee Orthoses (December 2016 through March 2017)

  • Noridian denied 838 out of 936 claims, for a claim denial rate of 90%.
  • The most common reasons for denial were:
    • the documentation did not support the applicable coverage criteria;
    • suppliers failed to respond to the Additional Documentation Request;
    • incomplete/missing information on Proof of Delivery forms; and
    • Noridian did not receive medical documentation from the supplier.

Ankle-Foot Orthoses (December 2016 through March 2017)

  • Noridian denied 136 out of 204 L1960 claims, for a claim denial rate of 67%.
  • Noridian denied 231 out of 319 L1970 claims, for a claim denial rate of 72%.
  • Noridian denied 314 out of 317 L4360 claims, for a claim denial rate of 99%.
  • The most common reasons for denial were:
    • the documentation failed to support the custom-fit criteria;
    • the documentation did not support the applicable coverage criteria;
    • suppliers failed to respond to the Additional Documentation Request. 
    • Noridian did not receive medical documentation from the supplier. 

What does this mean for you?

Based on these results Noridian will continue its prepayment claim reviews of both knee orthoses and ankle-foot orthoses. To successfully navigate these claim reviews you can take the following 5 steps.

  1. Review the applicable LCD's. The Local Coverage Determinations for Knee Orthoses and Ankle-Foot Orthoses spell out the coverage criteria that apply to each type of device. Make sure your claims have all the information listed in these documents and the associated Policy Articles. Also, check out our archives for relevant posts on the applicable coverage criteria (December 1, 2016 (AFO's), October 11, 2016 (KO's)).
  2. Respond to the ADR! We've said it countless times before and we'll say it again - you have an obligation to respond to every Additional Documentation Request, even if your claim does not, upon review, satisfy the applicable coverage requirements. Failure to respond results not only in a claim denial but a potential referral to the National Supplier Clearinghouse for further investigation.
  3. Document Your Deliveries. Medicare's requirements for an adequate proof of delivery are simple and clear. Make sure that for every item you deliver you fill out all of the necessary information.
  4. Get Medical Documentation. It's a basic requirement for all orthotic claims: your records have to document the medical necessity of the prescribed item AND the physician's must do so as well. You need both to have a valid claim.
  5. Watch Those Custom-Fit Criteria. You have to be able to show both substantial modification of the brace at the time of delivery and that the fitting at delivery requires a certified orthotist or person with equivalent training in order to use a custom-fit code. 

We will keep you updated about future prepayment claim review results as they become available. 

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