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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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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 October 1 and December 31, 2022. The error rate for this quarter is 67.47%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The HCPCS procedure code on the claim is not correct for the item(s) billed. 42.62%
2. The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (such as joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. 14.75%
3. The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 and Standard Documentation Requirements A55426. 9.84%
4. Supplier documentation does not include information to support the medical necessity of a custom fabricated device rather than a prefabricated orthosis. 6.56%
5. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. 3.28%
6. The author did not authenticate (handwritten or electronic) the medical record documentation. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. 3.28%
7. The treating practitioner's order, Certificate of Medical Necessity (CMN), supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9. 3.28%
8. Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. 3.28%
9. The medical records lack sufficient information to determine if the beneficiary's condition met medical necessity coverage criteria. 1.64%
10. The documentation does not contain a valid SWO. Refer to Standard Documentation Requirements A55426. 1.64%

*The total percentage will be greater than 100% because some claims were 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 represent an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Additional Education:

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