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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, L1851, L1852, and L2397 reviewed between April 1 and June 30, 2022. The error rate for this quarter is 55.10%. 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 (such as joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. 24.60%
2. The treating practitioner's order, Certificate of Medical Necessity, 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. 22.04%
3. No medical record documentation was received. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. 21.73%
4. The HCPCS procedure code on the claim is not correct for the item(s) billed. 7.99%
5. The medical record does not contain one of the diagnoses required by the local coverage determination (LCD). 6.71%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 4.15%
7. The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. 2.24%
8. The documentation submitted is incomplete. 1.60%
9. 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 and Standard Documentation Requirements A55426. 1.60%
10. The 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. 1.28%

*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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