The Medical Review Department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released modified second quarter 2016 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 April 1 and May 31, NGS performed a complex review of 607 claims. A total of 177 claims were allowed and 430 claims were denied, resulting in a claim error rate of 70.84%. A total of 156 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.
- No medical records were submitted.
- The ordering provider’s National Provider Identifier (NPI) did not match the provider’s NPI on the submitted claim.
- Current medical record documentation failed to indicate local coverage determination (LCD) coverage criteria has been met for the item ordered.
Based on the above results and findings, NGS said it will continue to monitor activity on the above-referenced HCPCS codes.