Jurisdiction D Posts Prepayment Review Quarterly Results for L-0631, L-0637

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Noridian Healthcare Solutions, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction D, has released the quarterly results of its service-specific prepayment reviews for LSO codes L-0631 and L-0637 from December 2016 through March. Based on the quarterly results, Noridian said it will continue the reviews.

The quarterly results are as follows:

·        The L-0631 (LSO sag-coro rigid frame pre) review involved 105 claims, of which 103 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98 percent.

·        The L-0637 (LSO sag-coronal panel prefab) review involved 135 claims, of which 130 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 96 percent.

The top reasons for denial are:

·        Documentation does not support custom fit criteria.

·        Documentation was not received in response to the Additional Documentation Request (ADR) letter.

·        Documentation does not support Pricing, Data Analysis and Coding (PDAC) approval.

·        Proof of Delivery (POD) was not received.