Noridian, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction A, posted results for quarterly service-specific prepayment reviews for AFOs and LSOs. The quarterly edit effectiveness results from July through October 2016 are as follows:
AFOs (L-1970, L-4360, L-4361)
The L-1970 (AFO plastic molded w/ankle j) review involved 126 claims, of which 106 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 84 percent. The L-4360 (Pneumati walking boot prefab) review involved 479 claims, of which 476 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99 percent. The L-4361 (Pneuma/vac walk boot pre ots) review involved 600 claims, of which 478 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 80 percent.
The top reasons for denial are:
- Documentation does not support custom fit criteria
- Documentation was not received in response to the Additional Documentation Request (ADR) letter
- Proof of delivery (POD) was not received
- Documentation does not support coverage criteria
Spinal Orthoses (L-0648 and L0650)
The L-0648 (LSO sag r an/pos pnl pre ots) review involved 296 claims, of which 257 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 87 percent. The L-0650 (LSO sc r ant/pos pnl pre ots) review involved 581 claims, of which 499 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 87 percent.
The top reasons for denial are:
- Documentation does not support coverage criteria
- Documentation was not received in response to the ADR letter
- Documentation contains a practitioner’s signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements
- POD is incomplete or missing elements
