National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) continues to conduct a widespread prepayment medical review of Comprehensive Error Rate Testing (CERT) high-error audit claims. Between January 1 and March 31, its medical review department performed a complex review of 3,250 claims, of which 1,749 claims were denied, resulting in a claim error rate of 53.82 percent.
The top denial reasons for O&P claims follow:
- The Healthcare Common Procedure Coding System (HCPCS) code(s) was not payable.
- No medical records were submitted.
- No documentation from the treating physician was submitted to support the beneficiary’s potential functional level.
- There was insufficient information from the treating physician, either on order or in the medical record, regarding physiological changes of the beneficiary resulting in the need for a replacement device.
- No information was submitted about the beneficiary’s history and current condition to support the designation of the functional level by the prosthetist.