National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released the results of its widespread prepayment medical review of spinal orthoses: TLSO and LSO, which includes the following Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640.
Between January 1 and March 31, NGS’ Medical Review Department performed a complex review of 424 claims. Eleven claims were allowed and 413 claims were denied, resulting in a claim error rate of 97.41 percent. A total of 131 claims were denied because documentation was not received in a timely manner.
Data collected during the first quarter identified the top denial reasons 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) coding verification
- No proof of delivery from the supplier
- The detailed written order was not submitted
- No medical records were submitted
Claims submitted from multiple suppliers were identified for review. Additional documentation was requested and the documentation received was reviewed to assure that all coverage criteria and documentation requirements were met. Based on the above results and findings, NGS said it will continue to monitor activity on these HCPCS codes through complex medical review.