The Medical Review Department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released fourth quarter 2015 results of its widespread prepayment review of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs), Healthcare Common Procedure Coding System (HCPCS) codes L-0450 through L-0640.
Between October 1, 2015, and December 31, 2015, 117 claims were allowed and 342 claims were denied, resulting in a claim error rate of 74.5 percent. A total of 125 claims were denied because documentation was not received in a timely manner. The top denial reasons were as follows:
- The documentation submitted did not include proof of delivery for the item(s) billed
- A detailed written order was not submitted
- No medical records were submitted
- The proof of delivery record did not include a sufficient detailed description to identify the item(s) delivered
- Current medical record documentation fails to indicate local coverage determination (LCD) coverage criteria has been met for the item ordered
Claims submitted from multiple suppliers were identified for review. Additional documentation was requested and the documentation received was reviewed to assure that all coverage criteria and documentation requirements were met, according to NGS. Based on the results, NGS said it will continue the complex medical review.
