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By Sandra Gauron, Appeals Coordinator

CGS announced that they will be conducting complex post-pay medical reviews on specific knee orthoses (L1833, L1851) and surgical dressing (A6196, and A6212) codes. 

These codes have been selected based on data analysis, which revealed that the allowed dollars for these codes have been significantly above expected amounts.  Further analysis revealed that they have also received multiple CERT errors.  

The post-pay reviews will only include claim dates prior to the Public Health Emergency (PHE) and will not include any during the PHE. CMS and the DME MACs are aware of the impact the PHE has had on the DMEPOS community and should be providing some flexibility. Suppliers should communicate with the DME MACs if more time is needed in responding to the Additional Documentation Request (ADR) letters

In the annoucement CGS also reminded suppliers of the importance of responding to Additional Documentation Request (ADR) letters. And even cited their authority to collect this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6). More importantly, suppliers are reminded that, if they do not comply with the response that they are in violation of Supplier Standard #28 (upon request, they fail to provide requested documentation to a Medicare contractor). Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

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