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David McGill Blogger

Region D's Bad AFO/KAFO Scores

Posted by David McGill | January 30, 2014

MAC Region D released the results of its ongoing prepayment claim review of AFO/KAFO claims involving codes L1970, L1960 and L4360 from September through December 2013. Here are the key findings.

  • The MAC denied 379 of 424 L1970 claims for an overall claim failure rate of 89%.
  • It denied 244 of 273 L1960 claims for an overall claim failure rate of 89%.
  • It denied 1538 of 1797 L4360 claims for an overall claim failure rate of 86%.

What does this mean for you?

First, based on these results, Region D will continue its prepayment review of these 3 codes. 

Second, the MAC emphasized several points that suppliers should take special note of:

  • "For custom-fabricated orthoses, there must be detailed documentation in the treating physician's records to support medical necessity of custom-fabricated rather than a prefabricated orthosis." [emphasis added]
  • Custom-fabricated AFO's and KAFO's must satisfy one of the following 5 criteria: (1) the beneficiary couldn't be fit with a prefabricated item; (2) the condition necessitating the orthosis is expected to be permanent or more than 6 months in duration; (3) there is a need to control the knee, ankle, or foot in more than one plane; (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 anatomical integrity or anthropometric proportions.

We've said since at least late 2012 that we expected the MACs and other Medicare contractors to start scrutinizing certain orthotic claims - particularly those for custom devices - in much the same manner as they have prosthetic claims since late 2011. Region A's RAC added AFOs to the list of devices it would examine just under a year ago​. In other words, this isn't limited to just one Region.

Lastly, the solution is plain: make sure that you comply with Medicare's coverage criteria and confirm that the doctor's medical record includes solid documentation as well.

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