Audit Alert: AFO & KAFO Orthoses

On July 5, 2017, Performant Recovery, the National DMEPOS RAC, added AFO and KAFO orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if basic coverage criteria outlined in the Local Coverage Determination (LCD) for AFO/KAFO Orthoses was met. Performant will review medical documentation provided to determine that services were reasonable and necessary.

Codes inlcuded in the audit are: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.

Per the LCD, Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

    1. Require stabilization for medical reasons, and
    2. Have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

Remember that for custom fabricated orthoses (L1904, L1907, L1920, L1940-L1950, L1960, L1970, L1980-L2034, L2036-L2038, L2106-L2108, L2126-L2128, L4631), there must be detailed documentation in the treating physician’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis. This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records and must be available upon request.

The RAC can look back three years from the claim paid date for claims in this audit.

Who else is watching?

Both Noridian and CGS have had AFOs and KAFOs on prepayment review for some time. Denials for these claims are mostly documentation related, in that the provided documentation does not meet the coverage criteria in the LCD or support that the orthosis provided was custom fit. It is important that you review the documentation prior to claim submission, and when necessary, refer back to the ordering physician if additional notes are required to support the orthosis.

This LCD also requires a KX modifier for certain HCPCS codes. Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in
the “Coverage Indications, Limitations and or Medical Necessity” section in the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

By appending the KX modifier to your claim, you are attesting to the fact that you have documentation to support the code billed to Medicare is medically necessary.

The van Halem Group can help! 

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.

Even more beneficial to you, is to allow our team to work for you proactively. Our clinical prescreen program provides reassurance that your documentation meets coverage criteria before you bill the claim. Our clinical team will review your claim prior to billing and work with you to obtain essential documentation from the ordering physician. Prescreens are charged on a per file fee.

For more information, contact us today!

 

References: 

AFO/KAFO LCD

AFO/KAFO Policy Article