On March 5, 2019, CMS updated the Proposed RAC Topics list to include Knee Orthosis within the RUL and Blood Glucose Test or Regeant Strips.
The automated review for Knee Orthoses within the RUL would join the Spinal Orthoses within the RUL if approved. The review would apply to claims for knee orthoses with dates of service within 90 days of the date of service of a previously paid knee orthoses for the same anatomical site. In instances where a second orthosis was provided during the 90 day timeframe, the claim would be denied as the reasonable useful lifetime requirement has not been met and an overpayment would be assessed.
If approved, codes L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852 and L1860 would be part of the automated review.
Also on the proposed list are Blood Glucose Test or Reagent Strips. If approved, the RAC (Performant Recovery) would conduct complex reviews of claims to determine if the quantity of glucose test strips (A4353) provided met the medical needs of the diabetic patient. As part of the complex review, the RAC will request documentation to determine if the utilization guidelines for blood glucose test strips (A4253) were met.
It is important to note that these audits are not yet approved by CMS, however, in the past all proposed topics have been moved to the "Approved RAC Topics" list.
Coincidentally, both types of equipment appeared in headlines last week when CMS announced initial details on the 2021 Competitive Bidding Program. Off-the-shelf knee orthoses were added to the product categories list to be included in Competitive Bidding while it was also announced that the National Mail Order Program for diabetes testing supplies will not continue for CB Round 2021.
Want some help? Come to the experts!
The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.
Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.
Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future. In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our prescreen program.
*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.
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