Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the quarterly results of its service-specific prepayment review of lower-limb prosthesis Healthcare Common Procedure Coding System (HCPCS) code L-5981 (all lower extremity prostheses, flex-walk system or equal). The quarterly review involved 28 claims from December 2013 through March 2014, of which 26 were denied. Based on dollars, this resulted in an overall potential improper payment rate of 93 percent. The top denial reasons were as follows:
- Documentation did not support the functional level billed on the claim.
- Documentation did not support the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
- Documentation did not support the medical necessity for the items requested.
- Records submitted were from a prosthetist/orthotist; documentation was not submitted from a physician.
Based on the results of this review, NAS said it will continue the prepayment service specific review.
NAS 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 Prostheses Local Coverage Determination (LCD) L11453 and Policy Article A25367. Suppliers can also review a specific policy Documentation Checklist for Lower Limb Prostheses on the NAS website.
