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

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 June 2015 through August 2015.

The review involved prepayment complex medical review of 1,068 claims submitted by 357 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 500 (47%) of the claims. For the remaining 568 claims, 17 claims were allowed and 551 claims were denied resulting in a claim denial rate of 97%. The overall CDR was 95.5%.

This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The overall Charge Denial Rate (CDR) is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed). The previous quarterly findings covered the period of March 2015 through May 2015 and resulted in a CDR of 81.8%.

Charge Denial Rate Historical Data

The following graph depicts the Charge Denial Rate from previous review periods to current:

Review Period Charge Denial Rate
April 2014 – August 2014 87.6%
August 2014 – December 2014 82.3%
December 2014 – February 2015 82.0%
March 2015 – May 2015 81.8%
June 2015 – August 2015 95.5%

Primary Reasons for Denial

Based on review of the documentation received, the following are the reasons for denial. Note that the percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also note that claims can be denied for multiple reasons therefore the percentages of reviews may not add up to 100%:

Detailed Written Orders Issues

  • Denied claims were missing a Detailed Written Order (DWO) (10.8%)
  • Denied claims included an incomplete DWO (26%)
    • DWOs submitted were not legible and/or did not list beneficiary name (2%)
    • DWOs missing start date and/or signature date (2.5%)
    • DWOs were missing a detailed description of the requested Lumbar Sacral Orthotic (s) The detailed description in the written order may be either a narrative description or a brand name/model number (10%)

Medical Record Documentation Issues

  • Denied claims missing the clinical documentation to support medical necessity (6%)
  • Denied claims upon review of clinical documentation (30%)
    • Medical documentation was not authenticated by the clinician conducting the exam (6%)
    • Clinician notes submitted did not support medical necessity. The documentation submitted did not demonstrate the treatment of an illness or injury to improve functioning of the spine or trunk on the body (24%)

Proof of Delivery Issues

  • Denied claims were missing the Proof of Delivery (POD) (9%)
  • Proof of Delivery (POD) included delivery documentation was missing required elements (8%)
    • Delivery documentation (Method 1) did not include signature of beneficiary or beneficiary’s representative; unable to determine if beneficiary received items billed (1%)
    • Dates of service do not match shipping/receipt dates for items, as defined within LCD (L33790) (1%)
    • Delivery documentation does not include delivery address (3%)
    • Delivery documentation does not specify the requested Lumbar-Sacral-Orthosis, and it is unclear from the description which orthotic is being delivered. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary. (3%)
Read the full release here: http://myemail.constantcontact.com/DME-MAC-JA-News—Results-of-Widespread-Prepayment-Review-of-Claims-for-Lumbar-Sacral-Orthoses–HCPCS-Codes-L0631-L0637.html
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