The Medical Review Department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released third quarter 2014 results of its prepayment review of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs), Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640. Between July 1 and September 30, 2014, NGS performed a complex review of 553 claims, of which 532 were denied, resulting in a claim error rate of 96.2 percent. Of the claims, 122 were denied because documentation was not received in a timely manner.
The top denial reasons were as follows:
- A detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary was not submitted.
- No Pricing, Data Analysis, and Coding (PDAC) contractor verification.
- No proof of delivery from the supplier.
- No medical records were submitted.
Additional details about the reasons for a specific claims denial can be found through the Medical Review Denial Tool on the NGS website.
