NHIC, the Jurisdiction A (JA) Durable Medical Equipment Medicare Administrative Contractor (DME MAC), posted results of the widespread prepayment review of claims for LSOs that were processed from December 2015 through February 2016. The two L-codes covered by this review are L-0631 (LSO sag-coro rigid frame pre) and L-0637 (LSO sag-coronal panel prefab). This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) contractor.
The review involved 974 claims submitted by 314 suppliers. Responses to additional documentation requests were not received for 283 claims (29 percent). For the remaining 691 claims, 88 claims were allowed (13 percent) and 603 claims were denied, resulting in a claim denial rate of 87 percent. The overall charge denial rate (CDR) was 86 percent. The CDR is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed).
The reasons for claim denials follow. Note that the percentages reflect the fact that a claim could have more than one missing/incomplete item, and claims can be denied for multiple reasons, therefore the percentages of reviews may not add up to 100 percent:
- Detailed written orders (DWOs): 17 percent of the denied claims were missing DWOs and 28 percent had • incomplete DWOs such that the DWOs submitted were not legible and/or did not list beneficiary name (7 percent), DWOs were missing dates of the order and/or signature date (11 percent), or DWOs were missing a detailed description of the requested LSO (10 percent).
- Clinical documentation issues: 3 percent of the denied claims were missing clinical documentation to support medical necessity and 85 percent had incomplete/invalid clinical documentation, such that medical documentation was not authenticated by the clinician conducting the exam (1 percent) or the documentation submitted did not meet the coverage criteria for a custom-fitted orthosis (84 percent).
- Proof of delivery (POD) issues: 16 percent of the denied claims were missing PODs and 11 percent had incomplete PODs, such that delivery documentation (Method 1) did not include the beneficiary’s or designee’s signature (1 percent), date(s) of service did not match shipping/receipt dates for items, as defined within the local coverage determination (L33790) (1 percent), delivery documentation did not include delivery address (1 percent), and delivery documentation did not specify the requested LSO, and it was unclear from the description which LSO was being delivered (8 percent).
Based upon these results, DME MAC JA said it will continue to review claims for LSO codes L-0631 and L-0637.
