Earlier this week, AOPA provided a summary on the first report of results of Target, Probe, and Educate (TPE) audits by Noridian Healthcare Solutions, the Jurisdiction D DME MAC contractor.
Since AOPA’s initial report which was limited to TPE results for “walking boot” orthoses, Noridian has published additional results for knee orthoses, spinal orthoses, and off the shelf diabetic shoes.
The newly published results by Noridian continue to show significant reductions in improper payment rates than were previously reported through the previous audit process which included an initial probe review followed by widespread pre-payment review.
As previously reported, the improper claim payment rate has dropped to 19% for walking boot style AFOs. New reports published by Jurisdiction D show that TPE audits for spinal orthosis showed a significant improvement with an improper claim payment rate of 34%. The improper payment rate for off the shelf diabetic shoes has been reduced to only 19%, a tremendous improvement over the almost 100% error rate during probe/widespread review audits.
Unfortunately, the results from the TPE audits for select knee orthosis codes has not improved as much as some of the other areas subject to TPE. While Noridian reported some improvement with an improper payment rate of 77%, the improper payment rate remains significantly higher than the other services selected for TPE review. Common errors reported by Noridian for the knee orthosis review included documentation that does not support coverage criteria, incomplete or missing detailed written order, documentation does not support custom fitted criteria, and failure to respond to the request for documentation.
In addition to reporting the results of the initial audits performed under the TPE program, the DME MACs have just released a “Dear Physician” letter for knee orthoses that is designed to educate referral sources about what documentation must exist in their medical records in order to support your claim for a knee orthosis. AOPA has reviewed the Dear Physician letter and believes it is consistent with existing LCD and Policy requirements for Medicare coverage of knee orthoses.
The TPE program is designed to provide up to 3 rounds of audits with personalized provider education after each round that is designed to address the specific reasons for claim denial. While there is clearly a need for improvement in documentation practices for knee orthoses, in general, the results published by Noridian are generally encouraging. AOPA will continue to monitor the DME MAC websites for additional results from the TPE program.