DME MAC B Releases TLSO/LSO 4Q Widespread Prepayment Review Update

The Medical Review Department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released fourth quarter 2014 results of its prepayment review of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs), Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640. Between October 1 and December 31, 2014, NGS performed a complex review of 571 claims, of which 547 were denied, resulting in a claim error rate of 95.8 percent. Of the claims, 157 were denied because documentation was not received in a timely manner.

The top denial reasons were as follows:

  • A detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary was not submitted.
  • No Pricing, Data Analysis, and Coding (PDAC) verification was submitted.
  • No proof of delivery from the supplier was submitted.
  • The detailed written order was not submitted.
  • No medical records were submitted.

Details about the reasons for a specific claims denial can be found through the Medical Review Denial Tool on the NGS website.