PrePay Claims Denials Orthoses
The reports include the reason for claims denial by product type, with references to the appropriate LCD.
JC DME, CGS, published reports on prepay claims reviews. The reports include the reason for claims denial by product type, with references to the appropriate LCD.
The listings below show the overall error rate for the category, and the number one reason for the denial, and a suggestion for alleviating the denial.
Ankle-Foot Orthoses (AFO), 49.74% denial rate. Number one reason for denial: the HCPCS code on the claims in not correct for the item billed.
Suggestion: when billing L1902, L1906, L1971, L4361, L4396, and L4397 be sure the product matches the description of those codes. Products billed with L1906 must be listed on the PDAC site (www.dmepdac.com).
Knee Orthoses (KO), 58.09% denial rate. Number one reason for denial: medical records do not support an examination of knee instability and objective description of joint laxity is present.
Suggestion: Educate the referring physician about the knee to document instability and joint laxity, in the medical records, when prescribing a KO.
Lumbar Sacral Orthoses (LSO), 37.56% denial rate. Number one reason for denial: HCPCS code on the claim is not correct for the items billed.
Suggestion: LSO products billed with HCPCS L0450-L0651 mostly require PDAC verification. Be sure to check the PDAC website for the product being dispensed for correct HCPCS code.
What Does This Mean for You?
Check the LCDs for the appropriate product to assure you are following the coding guidelines. Double-check the PDAC site for correct HCPCS code by product.