01-307 Orthopedic Footwear Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review of claims for Medicare DME billed on dates of service from January 1, 2019 through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

In 2019, the CERT Medicare Fee-for-Service Improper payment report noted an improper payment rate of 84.7% for this service category. This service type was listed in the top 20 service type improper payment rates for DMEPOS.

Orthopedic footwear is covered under the “leg, arm, back, and neck braces, and artificial legs, arms and eyes” benefit (Social Security Act §1861(s)(9)). Coverage is provided when coverage, coding and documentation requirements are met.

Reason for Review

The SMRC is tasked with performing claim review on a sample of Orthopedic Footwear claims from January 1, 2019 through December 31, 2019. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

HCPCS
Orthopedic Footwear and Accessories HCPCS listed below found in L33641 Orthopedic Footwear and A52481 Orthopedic Footwear

Base Shoe Codes: L3224, L3225, L3649

Accessory Codes: L3455, L3460, L3530, L3540, L3600, L3610, L3620, L3630, L3640, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3550, L3560, L3570, L3580, L3590 and L3595

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Detailed Written Order
  2. Dispensing Order, if applicable
  3. DME Documentation of continued need and use
  4. Documentation of the request for refill
  5. Supplier beneficiary information forms
  6. Proof of delivery
  7. Practitioner, nurse, and ancillary progress notes
  8. Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
  9. Medical record documentation to support the dates of service billed on the claim
  10. Documentation to support the code(s) and modifier(s) billed
  11. Documentation from the treating physician/practitioner to support the condition related to the DMEPOS item ordered
  12. History and Physical reports (include medical history and current list of medications)
  13. Medical record documentation that supports the specific reason the treating practitioner ordered a frequency/quantity that exceeds utilization guidelines
  14. Documentation from treating practitioner and/or supplier for servicing, repair, or replacement of DMEPOS
  15. Supplier’s record documentation showing the reason for item(s) being replaced
  16. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), Policy Article, and/or Standard Documentation Requirement Article (A55426) requirements
  17. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  18. List of all non-standard abbreviations or acronyms used, including definitions
  19. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  20. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  21. Any other supporting documentation or other pertinent information
  22. If medical record documentation is submitted via esMD; Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  23. PLEASE NOTE: It is the responsibility of the supplier/provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1815(a). Providers must furnish information
  • SSA, Title XVIII, Section 1833(e), (M). Payment of Benefits
  • SSA, Title XVIII, Section 1834(2)(A-B), (3), (5)(A-C)(F)(III), (h), (20)(G)(II). Special Payment Rules for Particular Items and Services
  • SSA, Title XVIII, Section 1861(n), (s)(6)(9). Miscellaneous Provisions
  • SSA, Title XVIII, 1862(a)(1)(A), (8). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, Section 1879(a)(1), (2), (h)(1-3). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA, Title XVIII, Section 1893(f)(7)(A)(B)(i-iv), (h)(4)(B). Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 42, Section 410.3. Scope of benefits
  • CFR, 36. Medical supplies, appliances, and devices: Scope and conditions
  • CFR, 410.38(g)(2). Durable Medical Equipment: Scope and Conditions
  • CFR, 411.15(f), (k)(1). Particular services excluded from coverage
  • CFR, 411.404. Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary
  • CFR, 411.406. Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary
  • CFR, 411.408. Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis
  • CFR, 414.200. Payment for Durable Medical Equipment and Prosthetic and Orthotic Device
  • CFR, 424.5(a)(4-6), (b). Basic Conditions
  • CFR, 424.57(c)(12). Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
  • CFR, 424.516. Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program
  • CFR, 424.535. Revocation of enrollment in the Medicare program
  • CFR, 424.57(c)(12). Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
  • Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01, Chapter 1, Section 10.3. Supplementary Medical Insurance (Part B) – A Brief Description
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 110. Durable Medical Equipment – General
  • MBPM, Pub 100-02, Chapter 15, Section 130. Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
  • MBPM, Pub 100-02, Chapter 15, Section 140. Therapeutic Shoes for Individuals with Diabetes
  • MBPM, Pub 100-02, Chapter 15, Section 290. Foot Care
  • MBPM, Pub 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 280.1. Durable Medical Equipment Reference List
  • Medicare NCD Manual, Publication 100-03, Chapter 1, Section 280.10. Prosthetic Shoe
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 20, Section 30.3. Certain Customized Items
  • MCPM, Publication 100-04, Chapter 20, Section 30.4. Other Prosthetic and Orthotic Devices
  • MCPM, Publication 100-04, Chapter 20, Section 30.9. Payment of DMEPOS Items Based on Modifiers
  • MCPM, Publication 100-04, Chapter 20, Section 40.1. General
  • MCPM, Publication 100-04, Chapter 20, Section 100. General Documentation Requirements
  • MCPM, Publication 100-04, Chapter 30, Section 50. Advance Beneficiary Notice of Non-coverage (ABN)
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.4. Additional Documentation Request Required and Optional Elements
  • MPIM, Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on Which to Base a Determination
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
  • MPIM, Publication 100-08, Chapter 3, Section 3.6. Determinations Made During Medical Review
  • MPIM, Publication 100-08, Chapter 4, Section 4.26 (7.3.1). Supplier Proof of Delivery Documentation Requirements
  • MPIM, Publication 100-08, Chapter 4, Section 4.26.1 (7.3.1.1). Proof of Delivery and Delivery Methods
  • MPIM, Publication 100-08, Chapter 4, Section 4.2 (4.7.3.1.2). Exceptions
  • MPIM, Publication 100-08, Chapter 4, Section 4.26.3 (4.7.3.1.3). Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries
  • MPIM, Publication 100-08, Chapter 5, Section 5.2. Rules Concerning DMEPOS Orders/Prescriptions
  • MPIM, Publication 100-08, Chapter 5, Section 5.7. Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs
  • MPIM, Publication 100-08, Chapter 5, Section 5.8. Supplier Documentation
  • MPIM, Publication 100-08, Chapter 5, Section 5.9. Documentation in the Patient’s Medical Record
  • MPIM, Publication 100-08, Chapter 5, Section 5.10. Supplier Documentation
  • MPIM, Publication 100-08, Chapter 5, Section 5.11. E vidence of Medical Necessity
  • MPIM, Publication 100-08, Chapter 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs
  • Local Coverage Determination (LCD) L33641. Orthopedic Footwear. Effective October 1, 2015
  • LCD L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis
  • Local Coverage Article (LCA) A52481. Orthopedic Footwear. Effective October 1, 2015
  • LCA A52457 Article for Ankle-Foot/Knee-Ankle-Foot Orthoses
  • LCA A55426. Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective January 1, 2017

Last Updated Jan 5, 2022