NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced results of its complex medical review for lower-limb prostheses Healthcare Common Procedure Coding System (HCPCS) codes billed with a K3 functional level modifier and components/additions provided. The review involved prepayment complex medical review of 258 claims submitted by 157 suppliers for claims processed August-December 2013. The review resulted in a Charge Denial Rate (CDR) of 50.9 percent.
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 or incomplete item.
- Lack of medical record documentation: 24.8 percent of the denied claims had no medical record information submitted.
- Evaluation/assessment documentation: 6 percent of the denied claims had no prosthetist records submitted.
- Clinical documentation did not support the functional level of the lower-limb prosthesis: 15.6 percent of the denied claims had clinical records submitted but the records did not justify the functional level of the billed item.
- Proof of delivery: 5 percent of the denied claims were missing the proof of delivery.
Based on the results of this prepayment review, NHIC said it will continue to review claims for lower-limb prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided.