NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has announced that its prepayment review of lumbar-sacral orthoses (LSOs) resulted in an overall charge denial rate of 83.3 percent. Based on the results, DME MAC A said it will continue to review LSO claims.
The claims prepayment review involved the prepayment complex medical review of 899 claims submitted by 89 suppliers. These claims were reviewed from January 13 through April 13, 2014. The review included Healthcare Common Procedure Coding System (HCPCS) codes L-0631 (LSO, sagittal control with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment) and L-0637 (LSO, sagittal-cornal control with rigid anterior and posterior frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment).
Responses to the Additional Documentation Request (ADR) were not received for 170 (19 percent) of the claims. For the remaining 729 claims, 104 claims were allowed and 617 were denied, resulting in a claim denial rate of 85 percent. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error divided by the total allowance amount of services medically reviewed) resulted in an overall charge denial rate of 83.3 percent. The LSO probe was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) contractor.
According to the documentation received, the following are the reasons for denial. The percentages reflect the fact that a claim could have more than one missing/incomplete item.
Detailed Written Orders Issues
- 15 percent of denied claims were missing a detailed written order for supplies being billed.
- 7 percent of the denied claims included an incomplete order.
- 13 percent of the denied claims were missing the clinical documentation to support medical necessity.
- 4 percent of the denied claims were due to no pertinent clinical documentation.
Medical Record Documentation Issues
Proof of Delivery Issues