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David McGill Blogger

They're Looking at Your Feet!

Posted by David McGill | September 24, 2013

MAC Region D has just announced a widespread prepayment targeted review of claims involving L5981 ("FLEX-WALK SYSTEM OR EQUAL"). This comes on the heels of a mid-August article from Region D finding that 81 of 99 claims involving L5981 purportedly failed to meet ​Medicare's requirements, an 82% failure rate.

When it published these results, Region D announced that it was closing its "probe review." With the data from that probe review giving it reason to take a deeper dive into the L5981 pool, the MAC has now decided to expand its inquiry.

What does this mean for you?

If you deliver an L5981 foot to a Medicare beneficiary in Region D, you will likely receive an Additional Documentation Request. That ADR will request 8 different pieces of information that you will need to provide: 

  1. Treating physician's dispensing and written order;
  2. Documentation of dispensing order (if item dispensed based on dispensing order);
  3. Patient's medical records (i.e., not yours; physician's, hospital's, nursing home's, home care nursing, PT/OT records)  supporting the medical necessity of the L5981 foot;
  4. Functional level documentation;
  5. Continued medical need of the L5981 foot;
  6. Proof of deliver;
  7. ABN (if applicable); and 
  8. Any other supporting documentation.
Knowing this, you must review all your L5981 claims moving forward to make sure that they contain this documentation. (As a practical matter, these are Local Coverage Determination requirements for all prosthetic foot claims, so this should already be standard operating procedure in your practice. If it isn't, however, then you need to implement it immediately for L5981 claims and quickly expand it to all prosthetic foot claims going forward.)

For readers not in Region D, we strongly recommend that you review your internal processes for prosthetic foot claims to make sure that they address each of these eight elements. Even though your Regions may not focus on L5981 claims right now, you should adopt a "worst-case scenario" mindset and prepare for increased scrutiny of foot claims in the future.

Lastly, remember to respond to all ADR requests from your MAC! Failure to do so may result in the MAC referring your business to the National Supplier Clearinghouse, putting your Medicare billing number (and entire business) in jeopardy. 
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