NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has announced the results of its complex medical review for lower-limb prostheses Healthcare Common Procedure Coding System (HCPCS) codes billed with a K-3 functional level modifier and components/additions provided. The review resulted in a Charge Denial Rate (CDR) of 66 percent.
The review involved prepayment complex medical reviews of 141 claims submitted by 97 suppliers for claims processed December 2012 to February 2013.
Responses to the Additional Documentation Request (ADR) were not received for 19 (13 percent) of the claims. For the remaining 122 claims, 28 claims were allowed and 94 were denied resulting in a claim denial rate of 77 percent. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error divided by the total allowance amount of services medically reviewed) resulted in an overall CDR of 68.3 percent.
According to the documentation received, the following are the reasons for denial. The percentages reflect the fact that a claim could have more than one missing/incomplete item.
- Lack of medical record documentation: 30 percent of the denied claims were missing the clinical documentation to corroborate the prosthetist’s records and support medical necessity.
- Evaluation/assessment documentation: 4 percent of the denied claims were missing the evaluation/assessment documentation for the functional level of item(s) billed (prosthetist assessment).
- Clinical documentation did not support the functional level of the lower-limb prosthesis: 32 percent of the denied claims had clinical records that did not justify the functional level of the billed item.
- Proof of delivery: 12 percent of the denied claims were missing the proof of delivery.
Based on the results of this prepayment review, NHIC said it will continue to review claims for lower-limb prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided. NHIC reminded suppliers that repeated failure to respond to ADRs could result in a referral to the Jurisdiction A Program Safeguard Contractor (PSC)/Zone Program Integrity Contractor (ZPIC).
NHIC has provided the following links to educational material so suppliers can be in compliance with documentation requirements:
- LCD for Lower Limb Prostheses (L11464) and related Policy Article (A25310).
- The DME MAC Jurisdiction A Supplier Manual (Chapter 10 includes information regarding documentation requirements.).
- Dear Physician Letter – Documentation of Artificial Limbs.
- Comprehensive Error Rate Testing (CERT) Errors (Monthly Publications).
- CERT Physician Letter – Documentation.
- Results of Widespread Prepayment Complex Review for Lower Limb Prostheses (Posted April 20, 2012; August 24, 2012 & December 28, 2012).
- Results of Widespread Prepayment Probe for Lower Limb Prostheses (Posted November 30, 2011).
