In this week's edition of the CMS Medlearn Matters newsletter CMS introduced the Provider Compliance Tips for Ordering Lower Limb Orthoses fact sheet. As background, the Medicare Fee-For-Service improper payment rate for lower limb orthoses was 66.7 percent, representing
a projected improper payment amount of $319.6 million. The fact sheet is written for DMEPOS Suppliers and provides detail into what the medical documentation should include to support need for the orthoses billed.
Noridian Healthcare Solutions, the DME MAC for Jurisdictions A and D, also published a Dear Physician Letter - Knee Orthoses. Dear Physician letters are created by the MACs to assist you in educating your referral sources. The letters explain the criteria for coverage and detail what the physician must document in their notes to effectively illustrate medical necessity.
If you supply lower limb orthoses to Medicare beneficiaries I encourage you to review these documents and share them with your referral sources. Orthoses continue to be one of the highest audited categories by all audit contractors. During an audit you will be required to provide medical documentation that supports the need for the orthoses. Insufficient documentation accounts for 92.2% of improper payments.
Make sure your claims are paid and you keep those payments. Request and review the ordering physician's documentation before you provide the orthoses. If the documentation does not include all of the elements outlined in the above mentioned resources, share these resources and request addendums.
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 orthoses you are providing meets coverage criteria? Sign up for our clinical prescreen review program.
Before you provide the orthoses, let our clinical staff review your documentation to ensure coverage criteria has been met. 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.
Contact us for more information!