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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 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)External Website. 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)External Website. 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:

Updated: May 21, 2024

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