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