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 82.3 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 1775 claims submitted by 338 suppliers. These claims were reviewed from August 29 through December 12, 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 486 (27 percent) of the claims. For the remaining 1,289 claims, 218 claims were allowed and 1,071 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 an overall charge denial rate of 82.3 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
- 19 percent of denied claims were missing a detailed written order for supplies being billed.
- 28 percent of the denied claims included an incomplete order.
Medical Record Documentation Issues
- 15 percent of the denied claims were missing the clinical documentation to support medical necessity.
- 30 percent of the claims were denied upon review of clinical documentation.
Proof of Delivery Issues
- 17 percent of denied claims were missing the proof of delivery.
- 17 percent of the denied claims included proof of delivery tickets that were missing required elements.