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David McGill Blogger

Region D Knee Orthosis Review Results and Pathways to Improvement

Posted by David McGill | October 02, 2017

​The DME MAC for Region D, Noridian, has published the results of a series of knee orthosis prepayment reviews over the last 60 days. Here's what you need to know:

  • The claim denial rates for the different reviews were 93%, 99%, 98% and 83%, respectively.
  • The top reasons for claim denials were
    • claim was the same or similar to another claim on file;
    • documentation was not received in response to the Additional Documentation Request letter;
    • documentation did not support the coverage criteria;
    • medical documentation was not received;
    • documentation did not support custom-fit criteria;
    • Proof of Delivery was incomplete or missing elements.

Based on these results, Noridian announced that it will continue its various reviews of knee orthoses.

What does this mean for you?

This series of reviews by Noridian yielding high claim denial rates prompts us to provide a comprehensive review of each of the top reasons for claim denial listed above. 

1. Same or Similar Claim on File

As we noted in our May 22, 2017 article, Noridian has published a Same or Similar Reference Chart. What this means is that (a) if you submit a claim for any of the codes listed on that chart, and (b) the Medicare beneficiary has previously received another device described by one of those codes, and (c) the reasonable useful lifetime of the earlier-delivered knee orthosis has not yet expired, Noridian will deny the current claim.

If you are in either Region A or Region D (both of which Noridian manages), you should be using either the Interactive Voice Response system or the Noridian Medicare Portal before delivering an item to make sure that the beneficiary has not received a same/similar item within the reasonable useful lifetime of that item. (Note: the Same or Similar Reference Chart is not limited to knee orthoses - it applies to all orthoses and DME items as well. Review the chart and use it for all items listed there.)

A reasonable question you might ask is, "But what if the earlier-provided knee orthosis was for a different clinical issue? Why should that trigger a same or similar denial?" We share that concern. But pending refinement of Noridian's approach, we are telling you simply what is. This is how Noridian is reviewing all orthotic claims, including knee orthoses: you should therefore operate - effective immediately - on that basis. Otherwise, expect to receive same/similar denials on your claims moving forward.

2. No Additional Documentation Request Letter Response

We have said it countless times in the past: when you get an ADR letter, you must respond. We know that sometimes you get the request, review your claim file and then realize that you are missing information that was required for a valid claim. Even in this instance, you should still draft a reply. 

Failure to respond to an ADR is grounds for the DME MAC to refer your business to the National Supplier Clearinghouse, the government contractor repsonsible for issuing (and revoking) your Medicare billing privileges. As a Medicare supplier, you have an affirmative obligation to respond to Medicare's/its contractors' requests for information. We cannot be clearer about this: always, always, always respond to an ADR. 

3. Documentation Didn't Support Coverage Criteria

The coverage criteria for knee orthoses are spelled out in the Local Coverage Determination for Knee Orthoses and the accompanying Policy Article. The LCD generally breaks knee orthoses into two broad categories - prefabricated and custom-fabricated - and then lists specific coverage criteria within each of these categories by specific L codes as follows:

Prefabricated Knee Orthoses

  • L1810, L1812, L1820
    • Beneficiary must be ambulatory;
    • Documented weakness or deformity of the knee; and
    • Documented need that knee requires stabilization.
  • L1831, L1836
    • Documented flexion or extension contractures of the knee; and
    • Movement on passive range of motion testing of at least 10 degrees.
  • L1847, L1848
    • Medicare denies claims for both of these codes based on its determination that the inflatable air bladders in these devices provide no proven clinical benefit.
  • L1830, L1832, L1833, L1843, L1845, L1851, L1852
    • Beneficiary has had a recent injury or a surgical procedure on the knee(s), or
    • For codes L1832, L1833, L1843, L1845, L1851, L1852
      • Beneficiary is ambulatory
      • Beneficiary has knee instability due to a condition specified in the "Group 4" diagnosis (ICD-10) codes listed in the LCD; and
      • Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test)
  • L1850
    • Beneficiary is ambulatory;
    • Beneficiary has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired; and
    • Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test
Custom-Fabricated Knee Orthoses

Custom-fabricated orthoses are covered when there is a documented physical characteristic that precludes use of a prefabricated device. Examples include, but are not limited to:
  1. Deformity of the leg or knee;
  2. Size of thigh and calf; and
  3. Minimal muscle mass upon which to suspend an orthosis.
If the medical record fails to include documentation showing why the custom-fabricated knee orthosis is required instead of a prefabricated item, Medicare will deny the claim.
  • L1834, L1840, L1844, L1846, L1860
    • Medicare denies claims for these codes for the treatment of knee contractures if the beneficiary is non-ambulatory.
  • L1834
    • Beneficiary cannot be fit with prefabricated device; and
    • Beneficiary has had a recent injury or a surgical procedure on the knee(s).
  • L1840
    • Beneficiary cannot be fit with prefabricated device; and
    • Documented instability due to internal ligamentous disruption of the knee.
  • L1844, L1846
    • Beneficiary cannot be fit with prefabricated device; and
    • Beneficiary has had a recent injury or a surgical procedure on the knee(s), or, alternatively
    • Beneficiary is ambulatory and
    • Beneficiary has knee instability due to a condition specified in the "Group 4" diagnosis (ICD-10) codes listed in the LCD, and 
    • Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test)
  • L1860
    • Beneficiary cannot be fit with prefabricated device; and
    • Beneficiary has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired; and
    • Knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test.
4. Medical Documentation Was Not Received

"Medical documentation" refers to the corroborating information from other health care providers without a financial interest in the claim: physician's office records; hospital records; nursing home records; home health agency records; records from other healthcare professionals; and test reports. You must obtain this information from the applicable health care provider and produce it to Medicare on request. If you fail to provide these corroborating records, Noridian will deny your claim.

5. Documentation Does Not Support Custom-Fit Criteria

In order to bill an orthosis as a custom-fit item, you must be able to show (a) substantial modification to the device (b) by a certified orthotist or individual with equivalent training (e.g., physician, treating practitioner, occupational therapist, physical therapist) (c) at the time of delivery. Your records must include a detailed description of the modifications made at the time of delivery.

6. Proof of Delivery Was Incomplete or Missing Elements

There are 3 ways you can deliver items to patients: (1) directly to the beneficiary/authorized representative; (2) via shipping/delivery service; or (3) to a nursing facility on the beneficiary's behalf.

Directly to Beneficiary/Authorized Representative

The POD form must include:
  • the beneficiary's name;
  • delivery address;
  • detailed description of item(s) delivered (e.g., brand name, serial number, narrative description, or HCPCS code long description);
  • quantity delivered;
  • date delivered (i.e., date beneficiary/designee received item);
  • beneficiary (or designee) signature.
Delivery Via Shipping or Delivery Service

The POD form must include all of the information listed above, plus the delivery service's package ID number, supplier invoice number, or an alternative method linking the supplier's delivery documents with the delivery service's records, and evidence of delivery. When using this method of delivery, the date of service for the claim is the date of shipping.

Delivery to Nursing Facility on Behalf of a Beneficiary

The POD form must demonstrate delivery of the item(s) to the facility by the supplier or delivery entity and include documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary.

Conclusion

We will keep you apprised of new claim review results from all of the DME MACs as information becomes available. In the meantime, review your claim processes to make sure that your claims satisfy the requirements discussed in this post.  

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