Noridian Administrative Services (Noridian), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has completed a widespread prepayment probe review of two lumbar sacral orthoses (LSOs), Healthcare Common Procedure Coding System (HCPCS) codes L-0631 (short code: LSO sag-coro rigid frame pre) and L-0637 (short code: LSO sag-coronal panel prefab). This review, which was initiated by Comprehensive Error Rate Testing (CERT) analysis, revealed high denial rates for both L-Codes.
The L-0631 review involved 101 claims of which 96 were denied, resulting in an overall error rate of 96 percent. The L-0637 review involved 100 claims of which 80 were denied, resulting in an overall error rate of 80 percent.
Primary documentation errors that resulted in denial of claims follow:
- Criteria 1 not met: 24 percent of L-0631 claims and 14 percent of L-0637 claims did not meet Criteria 1. The beneficiary’s medical records did not indicate the LSO order as reasonable and medically necessary as described in Local Coverage Determination (LCD) 11459, as follows:
A lumbar-sacral orthosis is covered when it is ordered for one of the following indications: (1) To reduce pain by restricting mobility of the trunk; (2) To facilitate healing following an injury to the spine or related soft tissues; (3) To facilitate healing following a surgical procedure on the spine or related soft tissue; or (4) To otherwise support weak spinal muscles and/or a deformed spine.
- Documentation does not support medical necessity: 23 percent of L-0631 claims and 13 percent of L-0637 claims did not support medical necessity for the item requested. The beneficiary’s medical records did not justify the LSO as medically reasonable and necessary. For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements.
- Proof of delivery not submitted: 14 percent of L-0637 claims and 7 percent of L-0631 claims were missing the proof of delivery.
- No documentation received: 12 percent of L-0631 claims were denied as no documentation was received.
- Billing requirements not met: 12 percent of L-0637 claims did not meet billing requirements.
Based on the high error rates, Noridian said it will close this probe review and begin a widespread, targeted review on L-0631 and L-0637.
Noridian has provided the following links to educational material so suppliers can familiarize themselves with the documentation requirements and utilization parameters as outlined in the Spinal Orthosis LCD L11459 and Policy Article A23846, Article for Spinal Orthoses: TLSO and LSO – Policy Article – Effective July 2010.