Knee Orthoses Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for knee orthoses HCPCS codes L1832, L1833, L1843, L1844, L1845, L1851, L1852, and L2397 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 55.88%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. | 44.04% |
2. | The medical record does not contain one of the diagnoses required by the Knee Orthoses – LCD (L33318)![]() |
17.43% |
3. | The HCPCS procedure code on the claim is not correct for the item billed. | 9.17% |
4. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 8.26% |
5. | Documentation provided in the supplier's records and the treating practitioner's medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis. | 3.67% |
6. | The documentation says the beneficiary returned the items. | 3.67% |
7. | We did not receive any medical record documentation. | 1.83% |
8. | There is not a valid handwritten or electronic signature by the author of the medical record. | 1.83% |
9. | The medical record documentation does not support the beneficiary has had a recent injury or a surgical procedure on the knee(s). | 1.83% |
10. | The documentation does not include a valid face-to-face encounter that meets the requirements in Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)![]() |
1.83% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Knee Orthoses Documentation Checklist
- Knee Orthoses – LCD (L33318)
- Knee Orthoses – Policy Article (A52465)
- Orthotics and Prosthetics Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024