National Government Services (NGS), the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction B, said it will continue to conduct a widespread prepayment medical review of Local Coverage Determination Spinal Orthoses: TLSO and LSO (L27017), which includes Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640.
Between July 1 and September 1, NGS’ medical review department performed a complex review of 289 claims from multiple suppliers. Sixty claims were allowed and 229 claims were denied, resulting in a claim error rate of 79.24 percent. Sixty-two claims were denied because documentation was not received in a timely manner. Additional documentation was requested and the documentation received was reviewed to assure that all coverage criteria and documentation requirements were met.
Data collected during the third quarter identified the top denial reasons as follows:
- Current medical record documentation failed to indicate local coverage determination (LCD) coverage criteria were met for the item ordered.
- The documentation submitted did not include proof of delivery for the item(s) billed.
- No medical records were submitted.
- The detailed written order (DWO) did not include a detailed description of the item(s).
- A DWO was not submitted.
Based on the above results and findings, NGS said it will continue to monitor activity on the above-referenced HCPCS codes through complex medical review.
