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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, 2023. The error rate for this quarter is 88.20%. 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.	40.57%
2.	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.	38.52%
3.	The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements.	4.51%
4.	No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8	2.87%
5.	The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.	2.05%
6.	The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).	2.05%
7.	The medical record does not contain one of the diagnoses required by the Knee Orthoses LCD (L33318).	1.64%
8.	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).	1.64%
9.	The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212	1.23%
10.	The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4	0.82%

*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:

Updated: February 2, 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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