NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has announced that its prepayment review of lumbar-sacral orthoses (LSOs) resulted in an 89 percent claim denial rate and an overall charge denial rate of 76.8 percent. Based on the results, DME MAC A will continue to review LSO claims.
The prepayment complex medical review included 107 claims submitted by 46 suppliers that were reviewed from July 16-September 27, 2013. The review included Healthcare Common Procedure Coding System (HCPCS) code L-0631 (LSO, sagittal control with rigid anterior and posterior panels, posterior extends from sacroccoccygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment) and L-0637 (LSO, sagittal-cornal control with rigid anterior and posterior frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment).
Responses to the Additional Documentation Request (ADR) were not received for 34 (31 percent) of the claims. For the remaining 73 claims, 8 claims were allowed and 65 were denied resulting in a claim denial rate of 89 percent. 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 of 76.8 percent. The probe was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) contractor.
According to the documentation received, the following are the reasons for denial. The percentages reflect the fact that a claim could have more than one missing/incomplete item.
Detailed written orders
- 33 percent of denied claims were missing a detailed written order for supplies being billed.
- 6 percent of denied claims were incomplete.
- 2 percent were not legible.
- 3 percent were not dated.
- 1 percent did not list a beneficiary name.
Medical record documentation
- 18 percent of the denied claims were missing the clinical documentation to support medical necessity.
- 5 percent of denied claims pertain to clinical documentation.
- 2 percent of the clinician notes submitted showed a different beneficiary than stated within the submitted claim.
- 1 percent of the clinician notes did not satisfy medical necessity. The documentation submitted did not demonstrate the treatment of an illness or injury to improve functioning of the spine or trunk on the body.
- 2 percent of the medical documentation was not authenticated by the clinician conducting the exam.
Proof of delivery
- 66 percent of the denied claims were missing the proof of delivery.
- 7 percent included delivery tickets that did not have the required documentation.
- 5 percent did not include signature of beneficiary or beneficiary representative on the delivery ticket; unable to determine beneficiary received items billed.
- 2 percent did not list beneficiary personal information on the delivery ticket; unable to determine beneficiary received items billed.
Items not specified in Pricing, Data, Analysis and Coding (PDAC)
- 85 percent of the denied claims were not specified in the product classification list on the PDAC web site. LSOs are described by specific codes and are required to meet specific requirements in order for CMS to reimburse suppliers for billed items. If the items billed cannot be located within the PDAC system; they are not recognized by Centers for Medicare & Medicaid Services (CMS).
NHIC provided the following links to educational material so suppliers can be in compliance with documentation requirements: