Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has announced the first quarter results of its widespread payment review of claims for AFO and KAFO Healthcare Common Procedure Coding System (HCPCS) codes L-1960, L-1970, and L-4360.
The results from December 2012 through March 2013 are as follows:
The L-1960 (ankle-foot orthosis, posterior solid ankle, plastic, custom fabricated) review involved 109 claims, of which 87 were denied (80 percent).
The L-1970 (ankle-foot orthosis, plastic with ankle joint, custom fabricated) review involved 63 claims, of which 53 were denied (86 percent).
The L-4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting & adjustment) review involved 564 claims, of which 474 were denied (84 percent).
The primary documentation errors that resulted in denial of claims were:
L-1960
- 22 percent of claims were denied because the treating physician’s records didn’t provide detailed documentation to support medical necessity of custom rather than prefab orthosis.
- 21 percent of claims received a denial because criteria 1, 2, 3, 4, or 5 were not met.
- 17 percent were denied because the documentation was insufficient to support basic coverage criteria.
L-1970
- 7 percent of claims lacked submitted proof of delivery.
- 25 percent of claims were denied because the treating physician’s records don’t provide detailed documentation to support medical necessity of custom rather than prefab orthosis.
- 22 percent of claims received a denial because criteria 1, 2, 3, 4, or 5 were not met.
- 13 percent were denied because the documentation was insufficient to support basic coverage criteria.
L-4360
- 23 percent of claims lacked submitted proof of delivery.
- 22 percent of claims received a denial as no detailed written order or dispensing order received.
- 19 percent were denied because the documentation was insufficient to support basic coverage criteria.
The NAS website describes the requirements for Criteria 1-5.
“AFO’s and KAFO’s that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria and one of the following criteria are met:
- The beneficiary could not be fit with a prefabricated AFO; or,
- The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
- There is a need to control the knee, ankle or foot in more than one plane; or,
- The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
- The beneficiary has a healing fracture which lacks anatomical integrity or anthropometric proportions.
If a custom-fabricated orthosis is provided but basic coverage criteria and the additional criteria 1-5 for a custom-fabricated orthosis are not met, the custom-fabricated orthosis will be denied as not reasonable and necessary.”
Because of the error rate, NAS will continue the prepayment widespread review.
