NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced the results of its widespread prepayment review of claims for LSOs, codes L-0631 and L-0637.
This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The previous quarterly findings covered the period of March through May and resulted in a Charge Denial Rate CDR of 81.8 percent. These findings include claims processed primarily from June through August. The review involved the prepayment complex medical review of 1,068 claims submitted by 357 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 500 claims. For the remaining 568 claims, 17 claims were allowed and 551 claims were denied resulting in a claim denial rate of 97 percent. The overall CDR was 95.5 percent.
Based on review of the documentation received, the following are the reasons for denial. The percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also, claims can be denied for multiple reasons, therefore the percentages of reviews may not add up to 100 percent.
Detailed Written Orders (DWO) Issues:
- 10.8 percent of denied claims were missing a DWO
- 26 percent of denied claims included an incomplete DWO
Medical Record Documentation Issues:
- 6 percent of denied claims were missing the clinical documentation to support medical necessity
- 30% of claims were denied upon review of clinical documentation as medical documentation was not authenticated by the clinician conducting the exam or clinician notes did not support medical necessity
Proof of Delivery (POD) Issues:
- 9 percent of denied claims were missing the POD
- 8 percent of claims were missing required elements of the POD delivery documentation
Based upon the results of this initial prepayment review, DME MAC A said it will continue to review claims for LSOs L-0631 and L-0637.