Category: DME Coding

DME MAC Jurisdiction B News from CGS

Posted on by DME INFO

CGS Medical Review Quarterly Reports by Policy

Analysis of claim denials for knee orthoses HCPCS codes L1833 and L1851 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 65.52%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for AFO HCPCS codes L1902, L1906, L1971, L4396, and L4397 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 30.79%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for lumbar sacral orthosis (LSO)HCPCS codes L0457, L0637, L0648, and L0650 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 38.37%. Please click here for the top 10 reasons for claim denials.

Analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A5500 and A5512-A5514 reviewed between April 1, 2021 and June 30, 2021 revealed a denial rate of 88.35%. Please click here for the top 10 reasons for claim denials.

 

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Results of Widespread Prepayment Review of Claims for Lumbar-Sacral Orthoses, HCPCS Codes L0631/L0637

Posted on by DME INFO

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

Knee Orthosis (HCPCS L1832, L1843) Quarterly Results of Service Specific Prepayment Review

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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

For complete post please click here

CORRECT CODING – DEFINITIONS USED FOR OFF-THE-SHELF VERSUS CUSTOM-FITTED PREFABRICATED ORTHOTICS (BRACES) – REVISED

Posted on by DME INFO

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

Please click here to read the entire article