Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has announced that it will conduct a widespread prepayment targeted review on Healthcare Common Procedure Coding System (HCPCS) code L-5981 (all lower extremity prostheses, flex-walk system or equal).
The review is being initiated based on Comprehensive Error Rate Testing (CERT) review analysis and previous review results. All suppliers billing Jurisdiction D for L-5981 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:
- Treating physician’s dispensing and written order.
- Documentation of dispensing order (if item is dispensed based on a dispensing order).
- Patient’s medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided are reasonable and necessary.
- Documentation to support the functional level modifier used.
- Continued medical need of the item.
- Proof of delivery.
- The Advanced Beneficiary Notice (if applicable).
- Any other supporting documentation.
Failure to supply the requested information within 45 days of the date on the ADR will result in the claim being denied. The ADR letter provided will also provide instruction for submitting documentation.
For more information, visit the NAS website.
