NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), posted results of its widespread prepayment review of claims for lumbar-sacral orthoses (LSOs), L-0631 (Lso sag r an/pos pnl pre cst) and L-0637 (Lso sc r ant/pos pnl pre cst) for claims processed primarily from March 2015 through May 2015. This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The overall Charge Denial Rate (CDR) is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed).
The review involved prepayment complex medical review of 1,384 claims submitted by 423 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 582 (42 percent) of the claims. For the remaining 802 claims, 148 claims were allowed and 654 claims were denied resulting in a claim denial rate of 82. The overall CDR was 81.8 percent. The previous quarterly findings covered December 2014 through February 2015 and resulted in a CDR of 82 percent.
Based on review of the documentation received, reasons for denial encompassed issues with detailed written orders, medical record documentation, and proof of delivery. DME MAC A said it will continue to review claims for LSOs coded L-0631 and L-0637.
