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David McGill Blogger

MAC Region A Announces New Prepayment Targeted Review

Posted by David McGill | April 21, 2017

​The DME MAC for Region A, Noridian, has announced that it will commence a "service specific prepayment targeted review" for lumbar orthoses described by the following L codes:

  • L0625
  • L0626
  • L0627
  • L0641
  • L0642

According to Noridian, reviews of this type "are initiated to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas." Noridian further states that "[t]his review is being initiated based on data analysis."

What does this mean for you?

If you operate in Region A and deliver lumbar orthoses with any of the aforementioned codes, any claims you file for them are potentially subject to this targeted review. You will be notified by an Additional Documentation Request (ADR) letter that will ask you to produce the following information:

  • Treating physician's dispensing and written order;
  • Dispensing order (if item is dispensed based on a dispensing order);
  • Patient's medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item provide is reasonable and necessary;
  • Justification to support the custom-fitted or off-the-shelf orthosis code billed;
  • Proof of delivery;
  • Advance beneficiary notice of non-coverage (if applicable);
  • Reason for replacement (if applicable); and
  • Any other supporting documentation.

Before filing any claims involving these L codes, make sure that you have or can produce the applicable documentation listed above in order to withstand the claim review. Also remember that if you fail to respond to the ADR letter within 45 days, the MAC will deny the claim.

We will keep you apprised of further developments and reports regarding this service specific prepayment targeted review as new information becomes available. In the meantime, use this news - whether you operate in Region A or not - as an excuse to review your internal processes and ensure that they meet the criteria listed above.

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