The last forum discussed the DMEPOS prior authorization program as one way of CMS stemming the flow of money to the provider and is done prior to services or DME being provided.
This edition of the forum will discuss one which is far too familiar to many readers, audits..
In the post Covid 19 era, CMS and other third-party payers have revved up their post payment audits. This is one way of recovering from the huge number of expenditures they sustained during Covid. Recently, CMS by way of the Recovery Audit Contractor (RAC) has targeted several custom fit device codes (e.g. L1951) for post payment audit and has been very successful in their efforts.
The first issue is to determine whether the patient clinically qualifies for a solid and rigid AFO as defined by L1951. Such issues as the patient’s ability for the ankle/foot to achieve neutral position in stance phase of gait. Other essential points to address during the examination are the absence of clonus or other myoclonic jerks. If the patient cannot be passively maneuvered into the neutral position of 90 degrees of the foot to the tibia, then they do not qualify for an L1951. If the patient has clonus or other abnormal contractures or reflexive movements which are active during gait, they also do not qualify for an L1951. It is therefore important to document the presence/absence of these issues in the chart at the time one determines the medical necessity for L1951.
It is important to understand that any code which contains the narrative (includes fitting and adjustment or custom fitted), must be customized to the patient by a qualified provider at the time of delivery. Custom fitting includes such examples as the DME MAC provides in their AFO LCD. The limited examples provided in the LCD include bending, heating, molding by a qualified provider at the time of delivery. But those are only examples and are not to be concluded as the only maneuvers which providers must perform at the time of delivery.
More on the specific issues facing providers dispensing L1951 in the final posting on this issue…
