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David McGill Blogger


Posted by David McGill | January 24, 2014

MAC Region D has released new prepayment claim review results, all of which focus on the K3 prosthetic foot code L5981. Here's what you need to know:

  • ​The review, which spanned September through December 2013, involved only 12 claims.
  • The MAC denied all 12.
  • Region D listed 4 reasons why it denied these claims, though it gave no breakdown of how many claims were denied for each reason(s):
    • No documentation supporting the medical need for  prosthetic foot replacement;
    • No physician documentation submitted;
    • Insufficient functional level documentation;
    • Insufficient proof of delivery.

What does this mean for you?

Based on these results, Region D announced that it will continue its prepayment review. However, two additional comments are in order.

First, even with the small sample size, the reasons for denial are part of the same broken record that keeps playing across every Medicare Region: no physician documentation; inadequate functional level documentation; inadequate proof of delivery; insufficient replacement item documentation. The MACs have clearly and consistently pointed to these kinds of claim errors over the past 12 months, so make sure you scrutinize your claims in all of these areas before filing them to ensure compliance.

Second, we're hearing anecdotal evidence that the "insufficient documentation for replacement items" basis for denial has become a special area of focus in more than just Region D. The simple fact that your patient has worn a prosthetic foot, knee or liner beyond the applica​ble warranty period does not automatically mean they need a new one. Rather, you have to demonstrate the medical need (necessity) for a replacement component, even if it's beyond the applicable warranty period.

Dot your "i's" and cross your "t's". 0 for 12 is not a good result in baseball, basketball, or prosthetic claims.

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