National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the results of its second quarter 2015 widespread prepayment medical review of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs), which includes Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640.
Between April 1 and June 30, NGS’ Medical Review Department performed a complex review of 445 claims. A total of 45 claims were allowed and 400 claims were denied, resulting in a claim error rate of 89.9 percent. A total of 167 claims were denied because documentation was not received in a timely manner.
Data collected during the second quarter identified the top denial reasons as follows:
- A detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary was not submitted.
- No medical records were submitted.
- The detailed written order did not include a detailed description of the item(s).
- Current medical record documentation fails to indicate local coverage determination (LCD) coverage criteria has been met for the item ordered.
Claims submitted from multiple suppliers were identified for review. Additional documentation was requested and the documentation received was reviewed to assure that all coverage criteria and documentation requirements were met. Based on the above results and findings, NGS said it will continue to monitor activity on these HCPCS codes through complex medical review.
