SAN FRANCISCO–(BUSINESS WIRE)–DJO Global, Inc., a leading global provider of medical technologies designed to get and keep people moving, unveiled their MotionMD® software solution at the 2016 Annual Conference of the American Association of Orthopaedic Executives (AAOE). Please click here to view the entire release.
NEW Orthotic braces–reasonableness of Medicare payments compared to amounts paid by other payers
We will determine the reasonableness of Medicare fee schedule amounts for orthotic braces. We will compare Medicare payments made for orthotic braces to amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending. We will estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for orthotic braces with those of non-Medicare payers. (OAS; W-00-15-35756; expected issue date: FY 2016).
NEW Orthotic braces–supplier compliance with payment requirements
We will review Medicare Part B payments for orthotic braces to determine whether durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements. Prior OIG work indicated that some DMEPOS suppliers were billing for services that were medically unnecessary (e.g. beneficiaries receiving multiple braces and referring physician did not see the beneficiary) or were not documented in accordance with Medicare requirements. Medicare requires that such items be “reasonable and necessary.” (Social Security Act § 1862(a)(1)(A).) Further, LCDs issued by the four Medicare contractors that process DMEPOS claims include utilization guidelines and documentation requirements for orthotic braces. (OAS; W-00-15-35749; expected issue date: FY 2016).
For the entire 2016 Work Plan please click here: 2016 OIG Work Plan
A directive from CMS requiring healthcare providers, payers, clearinghouses, and billing services to comply with the transition to ICD-10 by 1 Oct 2015, which means:
- All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
- ICD-10 diagnosis codes must be used for all health care services provided in the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures.
- ICD-10 has 69,000 codes—more than 4 times the 17,000 codes in ICD-9. The additional codes will enable practices to be more specific on claims forms in reporting the care provided to patients.
- ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims.
- The medical terminology has been modernized and is consistent throughout the code set.
- There are codes that have a combination of diagnoses and symptoms, which improves the specificity of the reporting allowing for more information to be reported to completely describe a condition.
For additional information please click here ICD-10
The DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS codes L0631 and L0637). These findings include claims processed primarily from March 2015 through May 2015. The review involved prepayment complex medical review of 1,384 claims submitted by 423 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 582 (42%) of the claims. For the remaining 802 claims, 148 claims were allowed and 654 claims were denied resulting in a claim denial rate of 82%. The overall CDR was 81.8%. Please click here for entire report
The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code(s) L1832 and L1843. The quarterly edit effectiveness results from January 2015 through April 2015 are as follows:
The L1832 review involved 89 claims, of which 89 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100%.
The L1843 review involved 93 claims, of which 92 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99%.
Top Denial Reasons
- The documentation does not justify the code selected for custom fitted versus off-the-shelf.
- The documentation does not support knee instability or that the beneficiary is ambulatory.
- No documentation was received in response to the Additional Documentation Request (ADR) letter.
- The Proof of Delivery (POD) is invalid.