Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) announced the quarterly results of its widespread payment review of claims for AFO and KAFO Healthcare Common Procedure Coding System (HCPCS) codes L-1960, L-1970, and L-4360.
The results from September through December 2013 follows:
The L-1960 (ankle-foot orthosis, posterior solid ankle, plastic, custom fabricated) review involved 273 claims, of which 244 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 90 percent.
The L-1970 (ankle-foot orthosis, plastic with ankle joint, custom fabricated) review involved 424 claims, of which 379 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 90 percent.
The L-4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment) review involved 1,797 claims, of which 1,538 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 denial of claims were as follows:
- The treating physician’s records did not provide detailed documentation to support medical necessity of a custom orthosis rather than a prefabricated orthosis.
- Documentation submitted was insufficient to support custom coverage criteria.
- Documentation submitted was insufficient to support basic coverage criteria.
- There was no detailed written order or dispensing order provided.
Based on the high error rate, NAS will continue with the prepayment widespread review.
