Medicare LCD Compliance, Checked Before You Bill

Every analysis runs against current Local Coverage Determination criteria — L33787 and beyond — so documentation gaps surface before the claim goes out, not in an audit two years later.

Policy changes. Your compliance check should too.

LCDs and policy articles are living documents. When the DME MACs revise criteria, every note graded against the old rules is a claim graded wrong. ClaimGrade ingests policy updates the same day they publish and re-checks its grading criteria, so your team is never billing against last quarter's rules.

That includes the details that actually sink O&P claims: K-level functional documentation, specific ADL evidence (Medicare rejects "improved mobility" — it wants "grocery shopping while carrying bags"), OTS-alternative rule-outs for orthoses, and the corroboration rules that treat prosthetist notes as part of the medical record but never sufficient on their own.

What the compliance check covers

Medical necessity per L-code

Each HCPCS code on the claim is validated against its own coverage criteria — base codes and additions alike.

Functional level (K-level) evidence

Does the documentation actually support the K-level implied by the componentry? Graded, not assumed.

ADL specificity

Vague functional statements are flagged with examples of the specific activity documentation Medicare expects.

Physician corroboration

The referring physician's record must stand on its own. ClaimGrade grades it independently of the supplier note.

Same-day policy updates

LCD and policy-article revisions are reflected in grading criteria the day they drop.

Audit-ready output

Criterion-level results you can keep with the chart, showing the note was validated before billing.

Compliance checking starts with AI chart note analysis — and when criteria fail on the physician side, generate the addendum request letter in one step.

Check a claim before the payer does

Run your next case through ClaimGrade and see which LCD criteria pass — and which would have been a denial.

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