CGS wants to remind suppliers and providers that knee orthosis coverage for codes L1832, L1833, L1843, L1844, L1845, L1846, L1851, and L1852 requires 1 of 2 pathways to meet coverage criteria:
Recent injury or surgical procedure or ambulatory with knee instability:
- The treating practitioner is responsible for understanding the appropriate treatment/testing necessary based on the beneficiary’s clinical presentation.
- Medical records must include documentation of the examination of the beneficiary and an objective description of joint laxity.
- Includes testing of the beneficiary (such as varus/valgus instability, anterior/posterior Drawer test, not all inclusive)
- The objective test needs to show that the test resulted in an instability of the knee
- Note: The instability of the knee joint is a result of insufficiencies in the ligaments of the knee complex. A result of instability is a separate finding from other deficits found on exam, such as a malalignment or meniscus conditions. A subjective statement of instability or an X-Ray report would not be sufficient documentation to support the findings of knee instability.
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CGS wants to remind suppliers and providers that orthotic devices are not covered if they do not meet the coverage criteria outlined in the Local Coverage Determinations (LCDs) for the HCPCS code prescribed at the time of service.
Devices provided prior to the start of medical necessity (for example, before the surgery), will not meet the coverage criteria. After surgery, if there is documentation of the medical necessity for the orthotic device(s), you can provide the item, keeping in mind there are many other payment rules related to the claim.
For orthotic devices that require Prior Authorization (PA) (L0648, L0450, L1832, L1833, and L1851), do not submit PA requests prior to the start of medical necessity (for example, before the surgery). After surgery, if the medical record documentation shows an emergent need for the device(s), you can submit an expedited request. If an expedited request is not feasible, append the ST modifier to the claim to bypass PA. Claims submitted with the ST modifier are subject to 100% prepayment review.
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The Centers for Medicare & Medicaid Services (CMS) released the 2023 durable medical equipment (DMEPOS) Medicare fee schedule with an increase of 8.7 percent.
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Pub 100-04 Medicare Claims Processing
The federal government’s effort to penalize hospitals for excessive patient readmissions is ending its first decade with Medicare cutting payments to nearly half the nation’s hospitals.
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Please click here for information about OaraScore® https://www.djoglobal.com/our-brands/djo-surgical/oara-score
CGS Medical Review Quarterly Reports by Policy
Analysis of claim denials for knee orthoses HCPCS codes L1833 and L1851 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 65.52%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for AFO HCPCS codes L1902, L1906, L1971, L4396, and L4397 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 30.79%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for lumbar sacral orthosis (LSO)HCPCS codes L0457, L0637, L0648, and L0650 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 38.37%. Please click here for the top 10 reasons for claim denials.
Analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A5500 and A5512-A5514 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 88.35%. Please click here for the top 10 reasons for claim denials.
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