NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), completed a widespread prepayment complex review of claims for lower-limb prostheses L-Codes billed with a K3 functional level modifier and has posted the results. 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 232 claims submitted by 139 suppliers for claims processed March 1 to June 1. Responses to the Additional Documentation Request (ADR) were not received for 39 (17 percent) of the claims. For the remaining 193 claims, 90 claims were allowed and 103 were denied resulting in a claim denial rate of 53 percent. The overall CDR was 50.6 percent. The previous quarterly findings resulted in a CDR of 45.7 percent.
Based on review of the documentation received, reasons for denial encompassed lack of medical record documentation (23 percent); clinical documentation did not support the functional level of the lower-limb prosthesis (12 percent); issues with proof of delivery (7 percent); and reason for replacement was not included (14 percent).
Based on the results of this prepayment review, DME MAC Jurisdiction A said it will continue to review claims for lower-limb prostheses L-Codes billed with a K3 functional level modifier and components/additions provided.