NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has announced that its latest widespread complex medical review of claims for lower-limb prostheses Healthcare Common Procedure Coding System (HCPCS) codes billed with a K3 functional level modifier and components/additions provided resulted in a claim denial rate of 69 percent.
The review results involved prepayment complex medical review of 145 claims submitted by 105 suppliers for claims processed February 2013 to April 2013. Responses to the Additional Documentation Request (ADR) were not received for 30 (21 percent) of the claims. For the remaining 115 claims, 36 claims were allowed and 79 were denied. 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 Charge Denial Rate (CDR) of 62 percent. Based on the results of this prepayment review, DME MAC A said it will continue its review.
The reasons for the latest denials were:
- Lack of medical record documentation: 27 percent of the denied claims were missing the clinical documentation to corroborate the prosthetist’s records and support medical necessity.
- Evaluation/assessment documentation: 8 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: 31 percent of the denied claims had clinical records that did not justify the functional level of the billed item.
- Proof of delivery: 15 percent of the denied claims were missing the proof of delivery. Delivery is missing items delivered, manufacturer name, and model number.
The percentages above reflect the fact that a claim could have more than one missing or incomplete item.
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) and CERT Physician Letter – Documentation.
- Results of Widespread Prepayment Complex Review for Lower Limb Prostheses, posted April 24, 2012; December 28, 2012; and March 6, 2013.
- Results of Widespread Prepayment Probe for Lower Limb Prostheses, posted November 30, 2011.
