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.
- LCD for Lower Limb Prostheses (L11464) and related Policy Article (A25310).
- The DME MAC Jurisdiction A Supplier Manual (Chapter 10 includes information regarding documentation requirements.).
- Dear Physician Letter – Documentation of Artificial Limbs.
- Comprehensive Error Rate Testing (CERT) Errors (Monthly Publications).
- CERT Physician Letter – Documentation.
- Results of Widespread Prepayment Complex Review for Lower Limb Prostheses (Posted December 28, 2012; March 06, 2013; June 14, 2013; October 25, 2013).
- Results of Widespread Prepayment Probe for Lower Limb Prostheses (Posted November 30, 2011).
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.
NHIC reminded suppliers that repeated failure to respond to additional documentation requests (ADRs) could result in a referral to the Jurisdiction A Program Safeguard Contractor (PSC)/Zone Program Integrity Contractor (ZPIC).
NHIC has provided the following links to educational material so suppliers can be in compliance with documentation requirements: