Reasons for Denial of Prior Authorization for LLP
In September, Medicare began prior authorization for certain Lower Limb Prostheses codes in four states (California, Texas, Michigan and Pennsylvania.) The DME MACs have released an article with information about reasons the prior authorization requests are denied.
The top reasons prior authorization requests are denied include:
- The order was missing or incomplete
- Medical documentation insufficient
- Medical record amendments, corrections, and delayed entries
- Medical record signature not authenticated
- Current functional level not fully documented
What does this mean for you?
Familiarize yourself with the elements required for the Standard Written Order (SWO). SWO must contain all the following elements: beneficiary's name or medicare beneficiary identifier (MBI), order date, and general description of the item.
- The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
- For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
- For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately): quantity to be dispensed (if applicable), treating practitioner name or National Provider Identifier (NPI), and treating practitioner's signature.
Collect corroborating medical documentation from the treating physician.
- The CP notes and the physician notes are required to support medical necessity. For additional information, review the Medicare Program Integrity Manual, Chapter 5.
Correct amendments of medical records.
- If the medical documentation is amended, there are certain procedures to follow. Learn about these processes at this site: https://www.cgsmedicare.com/articles/cope31711.html
Signatures on Medical Records must be authenticated.
- Review the CMS signature requirements and determine if a signature log or attestation statement is necessary.
The patient’s current functional level must be well documented.
- The CP records and the physician’s notes should include information about the patient’s past functional history, current condition, and future potential. Refer to the LCD for more information.
Be ready to submit your own prior authorizations beginning November 17, 2020 for dates of service December 1, 2020 and after. Familiarizing yourself with the requirements and making sure you are providing all the necessary elements will make the process move along more quickly.