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.
Joint DME MAC Publication
This is a revision to a previously published article 3/28/2014.
As part of the 2014 and 2015 HCPCS update, codes were created describing certain OTS orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the table at the end of this article for a listing of codes.
When providing these items suppliers must:
- Provide the product that is specified by the ordering physician
- Be sure that the ordering physician’s medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated)
- Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
- Have detailed documentation in the supplier’s record that justifies the code selected
DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS code:
L4360 (WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)
This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor. Please click here to see entire article: L4360 Probe
We recently passed the one year mark of the roll-out of CMS’s changes to HCPCS coding for orthotics. If you have been tracking this issue, you know that CMS made significant changes to the coding structure by establishing two separate categories of HCPCS orthotic codes: Off-the-Shelf (OTS) and Custom Fitted (CST). We thought this would be a good time to review these changes and their implications.
As a reminder, the CMS definitions for OTS and CST orthotics are included below:
OTS Orthotics: Require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Minimal self-adjustment is an adjustment that the beneficiary, caretaker for the beneficiary, or a supplier of the device can perform and that does not require the services of a certified orthotist or an individual who has specialized training.
Custom Fitted Orthotics: Require fitting by someone with specialized education, training, and experience in fitting and certification and/or licensing.
If you are a DJO customer you have probably noticed that DJO now lists two recommended HCPCS codes on applicable product labels: one code for OTS and another for CST. Each customer should carefully review the CMS requirements to determine which is the most appropriate code to bill. Although, for now, the Medicare reimbursement for an OTS code is the same as a CST code, you must still meet the Medicare CST requirements when you bill a CST code. Failure to do so could subject you to Medicare repayments and even fines in the face of a Medicare audit.
For commercial payors, this change has created quite a bit of confusion. While most commercial payors are recognizing the new codes, there are still some that do not. We recommend that you check with your commercial payors to see how they are addressing the new coding structure. Depending on what you find out, you may want to check your payor contracts to determine if updates are indicated. For example, are the OTS codes listed and, if so, is there an associated fee schedule? And don’t forget to audit your payments to ensure you are getting paid appropriately by both Medicare and private payors.
If you would like more information or have questions about these changes please feel free to reach out to your local DJO representative.