The medical review department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced the results of its widespread prepayment review of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs). Additional documentation was requested on the 100 claims that were reviewed after which 83 were denied. Included were 19 claims that were denied because documentation requested was not returned. This accounted for a claims error rate of 83 percent and a provider error rate of 84.25 percent.
The top issues contributing to these denials are:
- Insufficient description of the product on proof of delivery.
- Proof of delivery not provided.
- Medical records not provided.
- Insufficient medical record documentation to justify the medical need of the item billed.
- Medical record documentation was not timely for the date of service.
- Detailed written order not provided.
- Pricing, Data Analysis, and Coding (PDAC) contractor – product delivery not verified.
- Insufficient documentation to support a custom orthosis.
NGS reminded suppliers that failure to respond to requests for additional documentation is in violation of supplier standard 28, which states that: “Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.” NGS also encouraged suppliers to review the following resources in efforts towards quality improvement:
- The local coverage determinations (LCDs) and related policy articles for items that are billed by suppliers can be found under Medical Policy Center (LCDs).
- Policy Education provides additional information for medical policies.
- Chapter 8 of the Jurisdiction B DME MAC Supplier Manual documentation requirements.