The medical review department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released first quarter 2016 results of its widespread prepayment review of spinal orthosis, which includes Healthcare Common Procedure Coding System (HCPCS) codes L- 0450 through L-0640.
Between January 1 and March 31, NGS performed a complex review of 631 claims, of which 139 claims were allowed and 492 claims were denied, resulting in a claim error rate of 77.97 percent. A total of 158 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.
- Current medical record documentation failed to indicate local coverage determination (LCD) coverage criteria have been met for the item ordered.
- The proof of delivery record did not include a sufficient detailed description to identify the item(s) delivered.
- No medical records were submitted.
- The detailed written order did not include a detailed description of the item(s).
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. Based on the above results and findings, NGS said it will continue to monitor activity on these HCPCS codes through complex medical review.
