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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 67.82%. 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.	33.17%
2.	The HCPCS procedure code on the claim is not correct for the item billed.	23.76%
3.	The documentation does not have a valid Standard Written Order (SWO).	6.93%
4.	The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.	6.44%
5.	The medical record does not contain one of the diagnoses required by the Knee Orthoses – LCD (L33318).	5.45%
6.	The documentation submitted indicates the items were returned by the beneficiary.	3.96%
7.	The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.	3.47%
8.	The beneficiary was in an acute care hospital or skilled nursing facility on this date of service.	3.47%
9.	The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).	2.97%
10.	The file does not include medical records that support that the beneficiary is ambulatory.	1.98%

*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 bean overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: May 21, 2024

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

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

Knee Orthoses Pre-Pay Review Quarterly Status Report

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