CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor, released quarterly results of its pre-payment service-specific review for ankle-foot, knee, and spinal orthoses, and therapeutic shoes. The reviews were conducted October-December 2022.
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 41.35 percent.
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 66.83 percent.
Claim denials for spinal orthosis HCPCS codes L-0450-L-0651 had a denial rate of 66.45 percent. The top reason for claim denial for AFOs, knee orthoses, and spinal orthoses was that the HCPCS procedure code on the claim was 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 48.54 percent. The top reason for claim denial was: Medical record documentation did not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there was no verification that the beneficiary had one of the six conditions the Local Coverage Determination (LCD) specifies must be present for coverage.