DME MAC Jurisdiction B News from CGS

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.

 

Please click the links below for additional policy information.

Medicare Announces Rule to Protect Consumers from Surprise Medical Bills

Announcement is the first in a series of regulations aimed at shielding patients from increased financial hardships stemming from surprise medical bills

The Biden-Harris Administration, through the U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, and the Office of Personnel Management, issued “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers from surprise billing and balance billing. Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network and can happen for both emergency and non-emergency care. Balance billing, when a provider charges a patient the remainder of what their insurance does not pay, is currently prohibited in both Medicare and Medicaid. This rule will extend similar protections to Americans insured through employer-sponsored and commercial health plans.

Please click on these links for more information   Consumer Protection  / What you need to know

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

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

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

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