CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released quarterly results of its pre-payment service-specific review for ankle-foot, knee, and spinal orthoses, and therapeutic shoes. The reviews were conducted in July through September.
Claim denials for AFO Healthcare Common Procedure Coding System (HCPCS) codes L-1902, L-1906, L-1932, L-1971, L-2114, L-4360, L-4361, L-4386, L-4387, L-4396, and L-4397 had a denial rate of 36.85 percent.
The top reason for claim denial was: The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
Analysis of claim denials for knee orthoses HCPCS codes L-1832, L-1833, L-1843, L-1844, L-1845, L-1851, L-1852, and L-2397 revealed a denial rate of 57.69 percent. The top reason for claim denial was: The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (such as joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner.
Claim denials for spinal orthosis HCPCS codes L-0450-L-0651 had a denial rate of 41.2 percent. The top reason for claim denial was: The HCPCS procedure code on the claim is not correct for the item(s) billed.
Therapeutic shoes/inserts for diabetic persons HCPCS codes A-5500, A-5512, and A-5513 reviewed had a denial rate of 61.8 percent. The top reason for claim denial was: Medical record documentation does not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there is no verification that the beneficiary had one of the six conditions the Local Coverage Determination (LCD) specifies must be present for coverage.
