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 September 2015 through November 2015 and resulted in a CDR of 96.3%.
Current Review Results
DME MAC JA has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS Codes L0631/L0637). These findings include claims processed primarily from December 2015 through February 2016.
The review involved prepayment complex medical review of 974 claims submitted by 314 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 283 (29%) of the claims. For the remaining 691 claims, 88 claims were allowed (13%) and 603 claims were denied resulting in a claim denial rate of 87%. The overall CDR was 86%.
Charge Denial Rate Historical Data
The following graph depicts the Charge Denial Rate from previous review periods to current:
| Review Period | Charge Denial Rate |
| March 2015 - May 2015 | 81.8% |
| June 2015 - August 2015 | 95.5% |
| September 2015 - November 2015 | 96.3% |
| December 2015 - February 2016 | 86.0% |
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
- Missing a Detailed Written Order (DWO) (17%)
- Incomplete DWO (28%)
- DWOs submitted were not legible and/or did not list beneficiary name (7%)
- DWOs missing date of the order and/or signature date (11%)
- DWOs were missing a detailed description of the requested Lumbar Sacral Orthotic (s). The detailed description on the written order may be either a narrative description or a brand name/model number (10%)
Clinical Documentation Issues
- Missing clinical documentation to support medical necessity (3%)
- Incomplete/Invalid clinical documentation (85%)
- Medical documentation was not authenticated by the clinician conducting the exam (1%)
- The documentation submitted did not meet the coverage criteria for a custom fitted orthosis (84%)
Proof of Delivery Issues
- Missing Proof of Delivery (POD) (16%)
- Incomplete Proof of Delivery (POD) (11%)
- Delivery documentation (Method 1) did not include signature of beneficiary or designee (1%)
- Date(s) of service do not match shipping/receipt dates for items, as defined within LCD (L33790) (1%)
- Delivery documentation does not include delivery address (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. (8%)
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 clinical documentation, fitter notes, and a POD.
Missing: The DWO. 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.
Example 2:
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 modifications by a qualified provider were made to the orthotic prior to delivery.
Example 3:
Received: The supplier submitted a completed DWO, POD, clinical documentation and supplier notes.
Missing: The medical documentation submitted is dated 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.
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.
Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the JA 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:
