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Performant Recovery posted one new complex issue to their approved issues log this month.

Off-the-Shelf Knee Orthosis

On March 15, 2019, Performant Recovery, the National DMEPOS RAC, added Off-the-Shelf Knee Orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews to determine if the orthosis is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity requirements will be denied.

Code(s) included in the audit: L1812, L1820, L1830, L1831, L1833, L1836, L1848, L1850, L1851 and L1852

Dates of service: Claims having a “claim paid date” which is less than 3 years and on or after 10/01/2015

Applicable policy references:

1. Title XVIII, Social Security, §1833(e), Section 1862(a)(1)(A), Section 1834 (j), Section 1842(p)(4), Section 1861(s)
2. Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c), 405.986, and 424.57 (c)
3. Medicare Program Integrity Manual, Chapter 3, §3.2.3.8
4. Medicare Program Integrity Manual, Chapter 4, §4.26
5. Medicare Benefit Policy Manual, Chapter 15, §110
6. Medicare Program Integrity Manual, Chapter 5, Sections 5.2, 5.2.1, 5.2.2, 5.2.3, 5.2.7, 5.2.8, 5.7, 5.8, and 5.9
7. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L33318, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date 10/16/2017
8. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52456, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date: 01/01/2017
9. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018

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.

Contact us for more information!