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Medicare Audit Results: Orthosis

Noridian Orthoses Audit Results: October 2018- December 2018


AFOs and KAFOs: 34% Error Rate


Base benefit Requirement: Must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

COVERAGE CRITERIA:

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

1. Require stabilization for medical reasons, and,

2. Have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.

Knee Braces: 61% Denial Rate

Documentation does not support coverage criteria.

COVERAGE CRITERIA:

For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Diagnosis Codes That Support Medical Necessity Group 4 Codes section.

Last Updated Mar 05, 2019

Spinal Orthoses: 47% Denial Rate

Base Coverage Requirement: Must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Then it must be documented which of the following it is being used for:

A spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following indications:

1. To reduce pain by restricting mobility of the trunk; or

2. To facilitate healing following an injury to the spine or related soft tissues; or

3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or

4. To otherwise support weak spinal muscles and/or a deformed spine.

Top Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.

• Claim is the same or similar to another claim on file.

• Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.

• Documentation does not support coverage criteria.

The big miss by most companies failing the audits is that you must meet and document the base coverage requirement for the product category AND regular coverage requirements for the HCPCS. It is not an either or.

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