The Medical Review Department of Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the results of its widespread prepayment probe review of Healthcare Common Procedure Coding System (HCPCS) code L-5987 (all lower extremity prostheses, shank foot system with vertical loading pylon). The L-5987 review involved 99 claims, of which 81 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 79 percent. Based on the high error rate, NAS said it will close this probe review and begin a widespread targeted review.
The primary documentation errors that resulted in denial of claims were as follows:
- Documentation did not support the functional level billed on the claim.
- Documentation did not support medical need for replacement.
- Documentation did not support that the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
- Requested documentation was not received by the contractor within the allotted timeframe.
This review was initiated based on results of Comprehensive Error Rate Testing (CERT) analysis and previous review results.
Noridian has provided the following links to educational material so suppliers can familiarize themselves with the documentation requirements and utilization parameters as outlined in the Lower Limb Prosthesis Local Coverage Determination (LCD) L11453
