NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has completed its widespread prepayment review of claims for lumbar-sacral orthoses (LSOs), which shows an overall charge denial rate (CDR) of 87.6 percent. The probe was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) contractor. Based on the results, DME MAC A said it will continue to review LSO claims.
The review involved prepayment complex medical review of 2,166 claims submitted by 361 suppliers. These claims were reviewed from April 15-August 28, 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 sacroccoccygeal 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 887 (41 percent) of the claims. For the remaining 1,279 claims, 214 claims were allowed and 1,065 were denied, resulting in a claim denial rate of 83 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 the overall CDR of 87.6 percent.
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
- 25 percent of denied claims were missing a detailed written order.
- 5 percent of denied claims included an incomplete order.
Medical Record Documentation Issues
- 19 percent of denied claims were missing the clinical documentation to support medical necessity.
- 20 percent of denied claims upon review of clinical documentation.
Proof of Delivery Issues
- 15 percent of denied claims were missing the proof of delivery.
- 13 percent of delivery tickets were missing required elements.
