NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), published the results of its prepayment review for L-1940 (ankle foot orthosis, plastic or other material, custom-fabricated) and L-4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise). This is the first probe NHIC has done on these L-Codes; the reviews were initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.
L-1940, AFO: The review involved prepayment complex medical review of 114 claims submitted by 97 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 34 (30 percent) claims. For the remaining 80 claims, 20 were allowed and 60 were denied, resulting in a claim denial rate of 75 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 (CDR) of 78.5 percent.
The following are the primary reasons for denial. The percentages reflect the fact that a claim could have more than one missing or incomplete item.
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Clinical Documentation: 23 percent of the denied claims did not include clinical documentation; 11 percent did not provide documentation to support the medical necessity of a custom-fabricated rather than a prefabricated orthosis; 6 percent included medical records that were not authenticated by the author; 6 percent were missing medical records from the treating physician; and 5 percent did not meet the basic coverage criteria for beneficiaries with weakness or deformity of the foot and ankle, who require stabilization for medical reasons and have the potential to benefit functionally
- Detailed Written Order (DWO): 13 percent of the denied claims were missing a DWO; 8 percent included a DWO that was missing an order date/start date; 6 percent included a DWO that was missing the additions to the base code; 4 percent included a DWO that was missing the physician’s name; 4 percent included a DWO that was missing the item to be ordered; and 3 percent included a DWO that did not include a narrative description or a brand name/model number of the item being ordered
- Proof of Delivery (POD): 18 percent of the denied claims were missing a POD; 8 percent included a POD that was missing the delivery address; 3 percent included a POD that did not include a narrative description or a brand name/model number of the item being dispensed; 3 percent included a POD that did not include a quantity of the item delivered; and 3 percent included a method 1 POD in which the delivery date was different than the date of service
L-4360, pneumatic walking boot: The review involved prepayment complex medical review of 156 claims submitted by 123 suppliers. Responses to the ADR were not received for 61 (39 percent) claims. For the remaining 95 claims, 2 were allowed and 93 were denied. This resulted in a claim denial rate of 98 percent. The total denied allowance amount resulted in an overall CDR of 96.7 percent.
The following are the primary reasons for denial. The percentages reflect the fact that a claim could have more than one missing or incomplete item.
- Clinical Documentation: 97 percent of the denied claims did not meet the coverage criteria for a custom-fitted item; 15 percent of the denied claims did not include clinical documentation; 5 percent of the denied claims did not contain clinical documentation that demonstrated the beneficiary required the item requested; and 4 percent of the denied claims included medical records that were not authenticated by the author
- DWO: 52 percent of the denied claims were missing a DWO; 5 percent of the denied claims included a DWO that was missing an order date/start date; and 3 percent of the denied claims included a DWO that did not include a narrative description or a brand name/model number of the item being ordered
- POD: 63 percent of the denied claims were missing a POD and 11 percent of the denied claims included a POD that was missing the delivery address
Based on the results of these prepayment probe reviews, NHIC said it will continue with prepay complex widespread medical reviews of claims for L-1940 and L-4360.
