In an effort to help reduce the Comprehensive Error Rate Testing (CERT), NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), said it will be providing monthly claim examples reviewed by the CERT contractor that resulted in the top CERT Errors. NHIC said it expects these examples will assist suppliers to understand the CERT review process and to become familiar with the type of medical records requested.
The following examples are durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)-related errors cited during the CERT review for November 2012, for lower-limb prostheses local coverage determination (LCD) L-11464.
Date of Service: May 30, 2012
L-5321-LT: Above knee, molded socket, open end, SACH foot, endoskeletal.
L-5624-LT: Addition to lower extremity, test socket, above knee; number of units billed equaled two.
L-5631-LT: Addition to lower extremity, above knee or knee disarticulation, acrylic socket.
L-5650-LT: Addition to lower extremity, total contact, above knee or knee disarticulation socket.
L-5651-LT: Addition to lower extremity, above knee, flexible inner socket, external frame.
L-5671-LT: Addition to lower extremity, below knee/above knee suspension locking mechanism, excludes socket insert.
Material Received
- Order for the replacement items billed on this claim that was signed and dated by the physician.
- Physician letter of medical necessity.
- Unauthenticated Care Plan Oversight (CPO) evaluation dated April 10, 2012, which documents recommendations for prosthesis and components (but no documentation to support that the components and prosthesis replaced was provided). The prosthetist note was not authenticated but was later altered with a signature added.
Material Missing
- Authenticated prosthetist documentation of the replacement of the prosthesis, prosthetic components replaced, and the reason for replacement as required in the governing LCD.
- Documentation of the beneficiary’s past history, beneficiary’s current condition including the status of the residual limb and the nature of other medical problems.
- Documentation to support the beneficiary’s desire to ambulate and documentation to support physician oversight.
Date of Service: June 27, 2012
L-5020-RT-KX: Partial foot, molded socket, tibial tubercle height, w/ toe filler.
L5668-RT-KX: Addition to lower extremity, below knee, molded distal cushion; two units billed.
Material Received
- Order for billed items.
- Statement for therapeutic shoes.
- Procedure note dated June 6, 2012, for a right TMA.
- History and physical dated June 25, 2012, and July 3, 2012 (unsigned).
- Supplier evaluation delivery.
- Supplier adjustment appointment documentation.
- Progress note dated June 6, 2012, that documents ordering a custom brace.
Material Missing
- Documentation from the referring physician that includes an evaluation of the residual limb and gait and an assessment of the beneficiary’s rehabilitation potential, current functional capabilities, and expected functional potential with an explanation for the difference.
- Documentation to support that with prosthesis use the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
- Documentation to support the beneficiary’s desire to ambulate.
Information about LCDs and documentation requirements can be found on the NHIC website.
