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 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). For the October through December 2013 quarter, the L-0631 review involved 1,247 claims, of which 1,092 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 88 percent. The L-0637 review involved 757 claims, of which 628 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 83 percent.
The primary documentation errors that resulted in claims denial were as follows:
- 18 percent of L-0631 claims and 16 percent of L-0637 claims were denied because coverage criteria indicated in Spinal Orthoses LCD (L11459) was not met.
- 18 percent of L-0631 claims and 15 percent of L-0637 claims were denied because the proof of delivery provided was invalid.
- 17 percent of L-0631 claims and 13 percent of L-0637 claims were denied because the durable medical equipment (DME) 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 web site.
- 13.5 percent of L-0631 claims and 18 percent of L-0637 claims were denied because no documentation was received in response to the additional documentation request.
Based on the results of this review, NAS said it will continue the prepayment widespread review.
