Results of Widespread Prepayment Review for
HCPCS Code L4360 (Pneumatic Walking Boot)
Historical Review Results
This is the first DME MAC JA medical review for the Pneumatic Walking Boot, (HCPCS L4360). This medical review was initiated due to errors identified by a DME MAC JA medical review probe. 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 Pneumatic Walking Boot probe had a CDR of 96.7%, which was noted in the article published on November 25, 2015.
Current Review Results
DME MAC JA has completed the widespread prepayment review of claims for Pneumatic Walking Boot, (HCPCS L4360). These findings include claims with dates processed from January 1, 2016 through March 31, 2016.
The review involved prepayment complex medical review of 255 claims submitted by 167 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 91 (36%) of the claims. For the remaining 164 claims, 4 of the claims were allowed (2%) and 160 of the claims were denied, resulting in a claim denial rate of 98%. The overall CDR was 96.8%.
Charge Denial Rate Historical Data
The following data depicts the Charge Denial Rate from previous quarters to current:
| Review Period | Charge Denial Rate |
| Probe | 96.7% |
| January 2016 - March 2016 | 96.8% |
Primary Reasons for Denial
Based on review of the documentation received, the following are the primary reasons for denial. Note that the percentages detailed 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%.
Clinical Documentation (116%)
- 90% of the denied claims did not meet the coverage criteria for a custom fitted item.
- 9% of the denied claims did not include clinical documentation.
- 9% of the denied claims did not contain clinical documentation that demonstrated the beneficiary required the item requested.
- 7% of the denied claims included medical records that were not authenticated by the author.
Detailed Written Order (75%)
- 53% of the denied claims were missing a detailed written order (DWO).
- 7% of the denied claims included a supplier created detailed written order that was missing an order date/start date.
- 4% of the denied claims included a detailed written order that did not include a narrative description or a brand name/model number of the item being ordered.
Proof of Delivery (110%)
- 69% of the denied claims were missing a proof of delivery.
- 13% of the denied claims did not include a sufficiently detailed description to identify if the item(s) billed were delivered
- 15% of the denied claims included a proof of delivery that was missing the delivery address.
- 9% of the denied claims did not include quantity delivered.
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 L4360 Pneumatic Walking Boot claims:
Example 1
Received:
- A detailed written order which includes the beneficiary's name, date of the order, physician's name, detailed description of the item(s), and physician signature and signature date;
- Clinical documentation consisting of orthotist notes and physician's medical records, which included information that the beneficiary met the basic coverage criteria.
- Proof of delivery which includes the beneficiary's name, quantity delivered, date delivered and beneficiary (or designee) signature that validates that the beneficiary received the items that were billed.
Missing:
- Clinical documentation consisting of orthotist notes, which included information that the item was custom fitted.
- Proof of delivery which includes a delivery address.
Example 2
Received:
- A detailed written order which includes the beneficiary's name, date of the order, physician's name, detailed description of the item(s), and physician signature and signature date;
- Clinical documentation consisting of orthotist notes and physician's medical records, which included information that the beneficiary met the basic coverage criteria.
- Proof of delivery which includes the beneficiary's name, delivery address, quantity delivered, date delivered and beneficiary (or designee) signature that validates that the beneficiary received the items that were billed.
Missing:
- Clinical documentation consisting of orthotist notes, which included information that the item was custom fitted.
Example 3
Received:
- Clinical documentation consisting of orthotist notes and physician's medical records, which included information that the beneficiary met the basic coverage criteria.
Missing:
- A detailed written order which includes the beneficiary's name, date of the order, physician's name, base code of item ordered, and physician signature and signature date;
- Clinical documentation consisting of orthotist notes, which included information that the item was custom fitted.
- Proof of delivery.
Next Step
Based on the results of this prepayment review, DME MAC JA will continue to review claims for the Pneumatic Walking Boot, HCPCS L4360. 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.
Educational References
NHIC provides extensive educational offerings related to the proper documentation requirements for L4360 Pneumatic Walking Boot 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:
