CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released quarterly results of its post-payment service-specific review ankle-foot, knee, and spinal orthoses, and therapeutic shoes. The reviews were conducted October through December 2021.
The most common reasons for claim denials for AFO Healthcare Common Procedure Coding System (HCPCS) codes L-1902, L-1906, L-1971, L-4396, and L-4397 were as follows:
- The HCPCS procedure code on the claim is not correct for the item(s) billed. (17.09 percent)
- Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom-fitted orthosis to the beneficiary. (15.82 percent)
- The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation.(12.03 percent)
- The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. (11.39 percent)
The most common reasons for claim denials for knee orthoses HCPCS codes L-1832, L-1833, L-1844, L-1851, L-1852, and L-2397 were as follows:
- The file does not include medical records that support an examination of knee instability and an objective description of joint laxity (i.e., joint testing, anterior draw, posterior draw, valgus/varus test) from the treating practitioner. (39.13 percent)
- Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom-fitted orthosis to the beneficiary. (15.56 percent)
- The HCPCS procedure code on the claim is not correct for the item(s) billed. (10.43 percent)
- The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. (5.22 percent)
The most common reasons for claim denials for spinal orthosis LSO HCPCS code L-0450 through L-0651 were as follows:
- The HCPCS procedure code on the claim is not correct for the item(s) billed. (44.39 percent)
- No medical record documentation was received. (10.71 percent)
- The documentation does not contain a valid standard written order (SWO). (6.63 percent)
- The treating practitioner’s order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner’s attestation does not provide sufficient documentation of medical necessity.
The top reasons for claim denials for therapeutic shoes/inserts for diabetic persons HCPCS codes A-5500, A-5512, and A-5513 were as follows:
- Medical record documentation does not include a clinical foot evaluation either conducted by the certifying physician or approved, initialed, and dated by the certifying physician. Therefore, there is no verification that the beneficiary had one of the 6 conditions the local coverage determination (LCD) specifies must be present for coverage. (17.93 percent)
- The medical record documentation is not authenticated (handwritten or electronic) by the author. (43 percent)
- Documentation did not include a Statement of Certifying Physician. (5.43 percent)
