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David McGill Blogger

MAC Region D Prosthetic Foot Review Data

Posted by David McGill | March 24, 2016

The DME MAC for Region D (Noridian) has ​published its most recent data regarding claims for prosthetic feet described by L5980, L5981 and L5987. Here's what you need to know:

  • Noridian denied 101 of the 111 claims reviewed for an overall claim denial rate of 91%;
  • Noridian denied 100% of the L5980 claims (19 of 19);
  • Noridian denied 90% of the L5981 claims (46 of 51); and
  • Noridian denied 88% of the L5987 claims (36 of 41).

The top reasons for denial remain the same as those we have discussed repeatedly in the past:

  • No response by the supplier to Noridian's​ request for additional documentation;
  • Lack of documentation supporting the medical need for replacement;
  • Lack of documentation supporting the selected functional level;
  • Lack of documentation showing the patient will reach or maintain the selected functional level within a reasonable period of time/the patient is motivated to ambulate;
  • The DWO is incomplete or missing elements.

What does this mean for you?

While the sample sizes for each of the codes listed above are small, the overwhelmingly negative results ensure that Noridian will continue to scrutinize claims for these K3 prosthetic feet. If you are receiving denials for claims involving these codes, make sure that you:

  1. Respond to any and all requests for additional documentation;
  2. Thoroughly document the need for a replacement device based on 1 of the following 3 criteria - (i) a physiological change in your patient's condition, (ii) irreparable change in the device's condition, or (iii) repairs to the device would exceed 60% of the cost of replacing it;
  3. Comprehensively document the patient's functional level based on past history (if applicable) and current condition, and make sure that the physician's records corroborate yours;
  4. Demonstrate that the patient will receive the assigned functional level within a reasonable period of time and is motivated to ambulate;
  5. Comply with all of the LCD's requirements for a complete Detailed Written Order.​​

Successfully running through the claims gauntlet requires you to have a comprehensive and consistent pre-claims submission process. Shortcuts on the front end will only lead to denials in payment or outright denials on the back end. Take the time to do it right ... the first time.

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