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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, L1844, L1851, L1852, and L2397 reviewed between January 1 and March 31, 2022. The error rate for this quarter is 85.01%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. No medical record documentation was received. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. 31.73%
2. 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 the Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9. 28.88%
3. The HCPCS procedure code on the claim is not correct for the item(s) billed. 12.12%
4. 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, and valgus/varus test) from the treating practitioner. 9.98%
5. The documentation does not contain a valid standard written order (SWO). Refer to the Standard Documentation Requirements A55426. 4.81%
6. The file does not include medical records that support that the beneficiary is ambulatory. 3.39%
7. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. 1.96%
8. The documentation submitted is incomplete. 1.96%
9. The medical record does not contain one of the diagnoses required by the local coverage determination (LCD). 1.78%
10. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to the Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 & Standard Documentation Requirements A55426. 1.60%

*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:

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