Jurisdiction D Posts Orthosis Prepayment Review Results

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Noridian Healthcare Solutions, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction D, released quarterly results of its service-specific prepayment reviews for spinal orthosis codes L-0648, L-0650, AFO/KAFO code L-4361, and KO codes L-1832 and L-1843. The January through April quarterly results are as follows:

Spinal Orthoses

·        The L-0648 review involved 399 claims, of which 314 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 79 percent.

·        The L-0650 review involved 1,126 claims, of which 986 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 88 percent.

The top reasons for denial were:

·        Documentation does not support coverage criteria.

·        Documentation was not received in response to the additional documentation request (ADR) letter.

·        Proof of delivery (POD) is incomplete or missing elements.

·        Claim is the same or similar to another claim on file.

AFOs/KAFOs

·        The L-4361 review involved 704 claims, of which 462 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 66 percent.

The top reasons for denial were:

·        Documentation was not received in response to the ADR letter.

·        POD is incomplete or missing elements.

·        Documentation does not support coverage criteria.

·        Detailed written order was not received.

KOs

·        The L-1832 review involved 139 claims, of which 139 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100 percent.

·        The L-1843 review involved 117 claims, of which 117 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100 percent.