Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department, has released quarterly results for the widespread complex review it is conducting on Healthcare Common Procedure Coding System (HCPCS) codes L-0631 (short code: LSO sag-coro rigid frame pre) and L-0637 (short code: LSO sag-coronal panel prefab), which show high rates of improper payments.
For the July through September 2013 quarter, the L-0631 review involved 1,584 claims, of which 1,369 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 87 percent. The L-0637 review involved 528 claims, of which 453 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 86 percent.
The primary documentation errors that resulted in claims denial were as follows:
- 22 percent of L-0631 and 17 percent of L-0637 claims were denied as coverage criteria indicated in spinal orthoses Local Coverage Determination (LCD) L11459 was not met.
- 19 percent of L-0631 and 20 percent of L-0637 claims were denied as the proof of delivery provided was invalid.
- 17 percent of L-0631 and 15 percent of L-0637 claims were denied as the item did not have the required coding verification or the DME MAC was unable to verify the item as being listed on the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor website.
- 8 percent of L-0631 and 11 percent of L-0637 claims received a denial as no documentation was received in response to the additional documentation request.
Based on the results of the review, NAS said it plans to continue the widespread payment review. NAS recommends that suppliers be familiar with the documentation requirements and utilization parameters as outlined in L11459 and Policy Article A23846 .
For further details about the quarterly results, visit the NAS website.
