CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released quarterly results of its post-payment service-specific review 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-1971, L-4396, and L-4397 revealed a denial rate of 23.64 percent. The top reasons for claim denials were: Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary; the medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation; and the documentation does not contain a valid Standard Written Order (SWO).
Analysis of claim denials for knee orthoses HCPCS codes L-1833 and L-1851 revealed a denial rate of 64.33 percent. The top reasons for claim denials were: 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; supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary; and the medical record does not contain one of the diagnoses required by the Local Coverage Determination (LCD).
Claim denials for lumbar sacral orthosis (LSO) HCPCS code L-0650 revealed a denial rate of 34.63 percent. The top reasons for claim denials were: Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary; medical records do not support one of the four criteria for a spinal orthosis; and the medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met.
Analysis of claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A-5500 and A-5512-A-5514 reviewed revealed a denial rate of 56.02 percent. The top reasons for claim denials were: 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 file does not include medical records from the certifying physician; and the patient’s medical records do not indicate the presence of one or more of the six conditions the Local Coverage Determination (LCD) specifies must be present in order for the patient to meet coverage criteria for therapeutic shoes.
