Results of Widespread Prepayment Review of
Claims for Lumbar-Sacral Orthoses
(HCPCS Codes L0631/L0637)
Historical Review Results
This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The overall Charge Denial Rate (CDR) is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed). The previous quarterly findings covered the period of June 2015 through August 2015 and resulted in a CDR of 95.5%.
Current Review Results
DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS Codes L0631 and L0637). These findings include claims processed primarily from September 2015 through November 2015.
The review involved prepayment complex medical review of 1,511 claims submitted by 398 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 384 (25%) of the claims. For the remaining 1,127 claims, 26 claims were allowed and 1,101 claims were denied resulting in a claim denial rate of 98%. The overall CDR was 96.3%.
Charge Denial Rate Historical Data
The following graph depicts the Charge Denial Rate from previous review periods to current:
| Review Period | Charge Denial Rate |
| December 2014 - February 2015 | 82.0% |
| March 2015 - May 2015 | 81.8% |
| June 2015 - August 2015 | 95.5% |
| September 2015 - November 2015 | 96.3% |
Primary Reasons for Denial
Based on review of the documentation received, the following are the reasons for denial. Note that the percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also note that claims can be denied for multiple reasons therefore the percentages of reviews may not add up to 100%:
Detailed Written Orders Issues
- Denied claims were missing a Detailed Written Order (DWO) (20.4%)
- Denied claims included an incomplete DWO (11.9%)
- DWOs submitted were not legible and/or did not list beneficiary name (1.5%)
- DWOs missing date of the order and/or signature date (1.4%)
- DWOs were missing a detailed description of the requested Lumbar Sacral Orthotic (s) the detailed description in the written order may be either a narrative description or a brand name/model number (9%)
Clinical Documentation Issues
- Denied claims missing clinical documentation to support medical necessity (10.8%)
- Denied claims upon review of clinical documentation (88%)
- Medical documentation was not authenticated by the clinician conducting the exam (1.8%)
- Clinician/supplier notes submitted did not support medical necessity. The documentation submitted did not meet the coverage criteria for a custom fitted orthosis. As stated in the LCD, a prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise (86.2%)
Proof of Delivery Issues
- Denied claims were missing the Proof of Delivery (POD) (10.6%)
- Proof of Delivery (POD) included delivery documentation was missing required element (4.1%)
- Delivery documentation (Method 1) did not include signature of beneficiary or beneficiary's representative; unable to determine if beneficiary received items billed (1%)
- Dates of service do not match shipping/receipt dates for items, as defined within LCD (L33790) (1%)
- Delivery documentation does not include delivery address (1.1%)
- Delivery documentation does not specify the requested Lumbar-Sacral-Orthosis, and it is unclear from the description which orthotic is being delivered. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary. (1%)
Claim Examples
As an additional educational measure, the following are actual examples of claim denials. NHIC expects these examples will assist suppliers in understanding the medical review process and the common documentation errors that occur with Lumbar- Sacral Orthoses claims:
Example 1:
Received: The supplier submitted a completed DWO, clinical documentation, and a POD.
Missing: The documentation does not meet the coverage criteria for a custom fitted orthosis. There must be documentation from the supplier/fitter, which demonstrates extensive modifications were made to the orthotic prior to delivery. "This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary."
Example 2:
Received: The supplier submitted a completed DWO, POD, clinical documentation and supplier notes.
Missing: The clinical documentation submitted is after the date of service. It is unclear if the item requested was necessary at the time the orthotic was ordered. Entries in the beneficiary's medical record must have been created prior to, or at the time of, the initial date of service (DOS) to establish whether the initial reimbursement was justified based upon the applicable coverage policy.
Example 3:
Received: The supplier submitted clinical documentation, fitter notes, and a POD.
Missing: The dispensing order does not contain a verbal order from the physician and is not signed. There must be a completed DWO submitted with each claim. The fitter notes state "The brace was fitted to the beneficiary". This does not give enough information to determine that the orthotic was modified by a person with expertise, prior to delivery.
Next Step
Based upon the results of initial prepayment review, DME MAC JA will continue to review claims for Lumbar- Sacral Orthoses, HCPCS codes L0631/L0637.
DME MAC Jurisdiction A performs ongoing assessment of the effectiveness of its prepayment widespread reviews. One assessment is the Compliance Improvement Program (CIP), which measures suppliers' performance with providing complete and accurate supporting documentation and their response rate to Additional Documentation Requests (ADRs). When a supplier achieves and maintains high quality accuracy and ADR response rate over three (3) quarterly periods, the supplier will be temporarily removed from that particular widespread review. The supplier's authorized official will be notified and provided details of this decision.
Questions and comments can be sent to the DME MAC Jurisdiction A Provider Compliance mailbox at:
dme_mac_jurisdiction_a_provider_compliance@hpe.com
Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.
NHIC offers a self-service tool, Decision Desktop, which allows suppliers direct access to specific details about a claim decision for claims which have been selected for Complex Medical Review. This tool enables direct access to comprehensive information relating to the reason for denial along with saving time since it is no longer necessary to contact Customer Service for this information.
Decision Desktop can be accessed through the following link: http://www.medicarenhic.com/dme/mr.aspx
Educational References
NHIC provides extensive educational offerings related to the proper documentation requirements for Lumbar-Sacral Orthoses claims. Please ensure that the responsible supplier staff is aware of and references this educational material so that supporting documentation for your claims is compliant with all requirements:
