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Linda Collins Blogger

Common Denials for Lower Limb Prostheses Claims

Posted by Linda Collins | July 27, 2015

​Region D, Noridian Medicare, recently published an article with common CERT claims denial reasons for Lower Limb Prostheses. There are four main errors causing denials: missing DWO, insufficient documentation to support need for replacement, no proof the services were provided by a certified practitioner, and physician notes not supporting patient's functional level.

Detailed Written Orders

All prosthetic items billed to Medicare require a prescription/DWO signed and dated by a treating physician. A prosthetist may create the DWO. The physician must review, sign and date the document. For more information about Detailed Written Orders see "DWO = Detailed Written Order."

Documentation of Replacement

The Local Coverage Decision (LCD) for Lower Limb Prostheses states the treating physician must document the need for a replacement prostheses. The reason for replacement may include:

  • A change in the patient' physical condition such as weight gain/loss
  • Changes in the residual limb
  • A documented change in the patient's functional level
  • Irreparable damage to the prostheses

The physician's notes need to specifically state the need for replacement and provide detailed information about the reasons for replacement. The physician's and prosthetist's notes need to indicate the patient's current functional level, as well.

Services Provided by Qualified Practitioner

Per the Social Security Act 1834(h)(1)(F), no payment shall be made for custom fabricated orthotics or prosthetics unless the item is furnished by a qualified practitioner AND fabricated by a qualified practitioner or a qualified supplier at a facility that meets such criteria.  

Proof a qualified practitioner provided the prostheses may include:

  • Authenticated supplier records which includes credentials.
  • Signature log which includes credentials.
  • Signature attestation for unsigned documents which includes credentials.
  • Copy of their certification.

Be sure to sign all medical records and documents with your credentials. It is a good practice to maintain a signature log for all practitioners in your office.  For more information go to Medicare Learning Network's® MLN Matters® Article MM6698, "Signature Guidelines for Medical Review Purposes".

Physician Documentation Supporting Functional Level

Corroborating documentation in the physician's medical record must give a detailed review of the patient's past history, current condition and desire to ambulate.  Ossur R&R has downloadable resources addressing both of these issues in its Reimbursement Resources section

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