Noridian, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), posted quarterly results of service-specific prepayment reviews for two knee orthosis L-codes and two spinal orthosis L-codes. The quarterly edit effectiveness results from October 2016 through January 2017 follow:
Knee Orthoses: The L-1832 (KO adj jnt pos rigid support) review involved 273 claims, of which 272 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100 percent.
The L-1833 (KO adj jnt pos r sup pre ots) review involved 1,053 claims, of which 1,027 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98 percent. The top reasons for denial were:
- Documentation was not received in response to the Additional Documentation Request (ADR) letter
- Documentation does not support coverage criteria
- Documentation does not support custom fit criteria
- Medical record documentation was not received
- Proof of delivery (POD) was not received
Spinal Orthoses: The L-0648 (LSO sag r an/pos pnl pre ots) review involved 639 claims, of which 555 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 868 claims, of which 797 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 92 percent. The top reasons for denial were:
- Documentation does not support coverage criteria
- Documentation was not received in response to the ADR letter
- Proof of delivery (POD) is incomplete or missing elements
