Noridian Healthcare Solutions, who serves as the Jurisdiction D DME MAC has recently released the results of its ongoing pre-payment review for spinal orthoses described by L0648 and L0650 and knee orthoses described by L1832 and L1843.

From January until April, 2015, 154 claims for L0648 were reviewed and 101 were denied representing an overall claim denial rate of 66{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}. In the same timeframe, 153 claims for L0650 were reviewed and 106 were denied representing an overall denial rate of 69{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}.  The top reasons for denial were no documentation submitted, invalid proof of delivery, no dispensing or detailed written order, and no documentation supporting the need for replacement.
Based on the denial rates, Noridian will continue its pre-payment review for these codes.

From January until April 2015, 89 claims for L1832 were reviewed, all of which were denied representing an overall denial rate of 100{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}. In the same timeframe, 93 claims for L1843 were reviewed and 92 were denied for an overall denial rate of 99{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}.  The top reasons for denial were no documentation submitted, lack of documentation supporting the medical need for a custom fitted device rather than an OTS device, no documentation of knee instability or ambulatory status of the beneficiary, and invalid proof of delivery.  Based on the denial rates, Noridian will continue its pre-payment review for these codes.

AOPA’s take on the results of both of these pre-payment reviews is that the DME MACs are now actively enforcing the revised proof of delivery requirements published in February, 2015 as well as the policy requirement regarding the need to document the specific modifications that were made to a device in order to justify billing it as custom fitted.   These are both recent, but significant changes to coverage policy and are actively contributing to higher claim denial rates during pre-payment reviews.

O&P providers must continue to be diligent in making sure that policy requirements are met, regardless of whether they or AOPA believe they are fair.  Failure to comply with these policy changes will only contribute to higher error rates which in turn lead to additional pre-payment reviews.

AOPA’s Take,  Where you go…..When you need to know!