Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has announced that it will be initiating a widespread prepayment review of claims for each of the following Healthcare Common Procedure Coding System (HCPCS) codes:
- L-5980: All lower extremity prostheses, flex foot system.
- L-5981: All lower extremity prostheses, flex-walk system or equal.
- L-5987: All lower extremity prostheses, shank foot system with vertical loading pylon.
This review is being initiated based on the results of Comprehensive Error Rate Testing (CERT) analysis and previous review results. According to NAS, all suppliers billing Jurisdiction D for the above-listed HCPCS codes are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following information to determine if the item billed complies with the existing reasonable and necessary criteria:
- The treating physician’s dispensing and written order.
- Documentation of dispensing order, if applicable.
- Patient’s medical records that support the item(s) provided is reasonable and necessary.
- Documentation to support the functional-level modifier used.
- Proof of delivery of item(s) ordered.
- The Advanced Beneficiary Notice, if applicable.
- Any other supporting documentation.
The ADR letter will also provide instructions for submitting documentation. Failure to comply within 45 days of the date on the letter will result in the claim being denied.
For more information, visit the NAS website.
