Results of Widespread Prepayment Complex Review for
Lower Limb Prostheses
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 resulted in a CDR of 34.6%. A summary of findings was published on the NHIC, Corp. Website on January 28, 2016. Based on this result, a widespread prepayment review was continued.
Current Review Results
DME MAC JA has completed a widespread prepayment complex review of claims for Lower Limb Prostheses HCPCS codes billed with a K3 functional level modifier.
The review involved prepayment complex medical review of 178 claims submitted by 123 suppliers for claims processed December 06, 2015 to March 01, 2016. Responses to the Additional Documentation Request (ADR) were not received for 13 (7%) of the claims. For the remaining 165 claims, 85 claims were allowed and 80 were denied resulting in a claim denial rate of 49%. The overall Charge Denial Rate was 34.6%.
Charge Denial Rate Historical Data
The following chart depicts the Charge Denial Rate from previous quarters to current:
| Review Period | Charge Denial Rate |
| March 2015 - June 2015 | 50.6% |
| June 2015 - September 2015 | 42.1% |
| September 2015 - December 2015 | 38.8% |
| December 2015 - March 2016 | 34.6% |
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.
Lack of Medical Record Documentation
- 26% of the denied claims had no medical record information submitted.
Clinical documentation did not support the functional level of the Lower Limb Prosthesis
- 20% of the denied claims had medical records submitted but the records did not support the functional level of the billed item(s).
Proof of Delivery
- 6% of the denied claims were missing a valid Proof of Delivery.
Reason for Replacement
- 36% of the denied claims had no statement or reason for replacement either on the physician's order or in the medical documentation.
Claim Examples
As an additional educational measure, the following are actual examples of claim denials. NHIC, Corp. expects these examples will assist suppliers in understanding the medical review process and the common documentation errors that occur with Lower Limb Prostheses claims.
Example 1:
Received: The supplier submitted a Detailed Written Order, which includes the beneficiary's name, specific items or components to be dispensed, treating physician's signature, date of clinician's signature and date of the order; An invoice of items that were billed, which includes the manufacturer, model numbers and cost of each item; and the prosthetist's evaluation/assessment documentation detailing the functional level of the items billed.
Missing: Clinical documentation to support functional level of the device and to corroborate the prosthetist's records. Proof of Delivery verifying that the beneficiary received the items that were billed.
Example 2:
Received: The supplier submitted a Detailed Written Order, which includes the beneficiary's name, specific items or components to be dispensed, treating physician's signature, date of clinician's signature and date of the order; Proof of Delivery that includes the manufacturer, model numbers, verifying that the beneficiary received the items that were billed; The prosthetist's evaluation/assessment detailing the functional level of the items billed; Clinical documentation to support functional level of the device and to corroborate the prosthetist's records.
Missing: Information by the ordering physician, either on the Detailed Written Order or in the medical record, demonstrating the reason for replacement.
Example 3:
Received: The supplier submitted a Detailed Written Order, which includes the beneficiary's name, specific items dispensed, treating physician's signature and date, and date of the order; Proof of Delivery that includes the manufacturer, model numbers, verifying that the beneficiary received the items that were billed; and the prosthetist's evaluation/assessment documentation detailing the functional level of the items billed.
Missing: The submitted clinical documentation did not support the functional level of the device and did not corroborate the prosthetist's records. Since the prosthetist is a supplier, the prosthetist's records must be corroborated by the information in the medical record.
Next Step
Based on the results of this prepayment review, DME MAC JA will continue to review claims for Lower Limb Prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided.
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.
Questions and comments can be sent to the DME MAC Jurisdiction A Provider Compliance mailbox at:
dme_mac_jurisdiction_a_provider_compliance@hpe.com
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 Lower Limb Prostheses 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:
