NHIC, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), recently announced the results of its widespread prepayment review of lumbar-sacral orthoses (LSOs) for Healthcare Common Procedure Coding System (HCPCS) codes L-0631 (LSO, sagittal control with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment) and L-0637 (LSO, sagittal-coronal control with rigid anterior and posterior frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment).
The prepayment complex medical review involved 1,511 claims submitted by 398 suppliers. These findings include claims processed primarily from September-November 2015. The review included Responses to the additional documentation request (ADR) were not received for 384 (25 percent) of the claims. For the remaining 1,127 claims, 26 claims were allowed and 1,101 claims were denied, resulting in a claim denial rate of 98 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 of 96.3 percent.
According to the documentation received, the following are the reasons for denial. The percentages reflect the fact that a claim could have more than one missing/incomplete item.
Detailed Written Orders Issues
- 20.4 percent of denied claims were missing a detailed written order for supplies being billed.
- 11.9 percent of the denied claims included an incomplete order.
Clinical Documentation Issues
- 10.8 percent of the denied claims were missing the clinical documentation to support medical necessity.
- 88 percent of the claims were denied upon review of clinical documentation.
Proof of Delivery Issues
- 10.6 percent of denied claims were missing the proof of delivery.
- 4.1 percent of the denied claims included proof of delivery tickets that were missing required.