Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has released quarterly results for its service-specific review of lower-limb prosthesis Healthcare Common Procedure Coding System (HCPCS) code L-5980 (all lower-extremity prostheses, flex foot system).
The review involved 48 claims from May through August 2014, of which 40 were denied. Based on dollars, this resulted in an overall potential improper payment rate of 83 percent. The top denial reasons were as follows:
- Documentation did not support the functional level billed on the claim.
- Medical record documentation did not support medical need for replacement.
- Medical record documentation did not support that the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
- Medical record documentation did not support that the beneficiary was motivated to ambulate.
- The documentation submitted was not properly authenticated.
Based on the results of this review, NAS will continue with the prepayment service-specific review.
