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David McGill Blogger

Region D Posts New Spinal and AFO/KAFO Review Data

Posted by David McGill | June 22, 2017

​The DME MAC for Region D, Noridian, published the latest claim review data for both spinal orthoses (L0648, L0650) and AFOs/KAFOs (L4361). Here's what you need to know:

Spinal Orthoses

  • Claim review period was Jan.-Apr. 2017.
  • The L0648 review involved 399 claims, 314 of which were denied for a 79% claim denial rate.
  • The L0650 review involved 1,126 claims, 986 of which were denied for an 88% claim denial rate.
  • The top denial reasons were (1) documentation failed to support coverage criteria, (2) no response to the Additional Documentation Request, (3) incomplete or missing proof of delivery, and (4) claim is the same or similar to another claim on file. 

AFOs/KAFOs

  • Claim review period was Jan.-Apr. 2017.
  • The L4361 review involved 704 claims, of which 462 were denied for a 66% claim denial rate. 
  • The top denial reasons were (1) documentation failed to support coverage criteria, (2) no response to the Additional Documentation Request, (3) incomplete or missing proof of delivery, and (4) the supplier failed to produce a detailed written order.

What does this mean for you?

Based on these results, Noridian will continue its prepayment claim review of both types of orthoses. In the meantime, you can and should take the following steps to make sure your claims satisfy Medicare's requirements.

First, review the Local Coverage Determinations for both spinal orthoses and AFOs/KAFOs and the related Standard Documentation Requirements for All Claims Submitted to DME MACs document. The coverage requirements are spelled out clearly in these documents and your claim must satisfy all the elements outlined in them.

Second, as we say over and over again in posts summarizing claim review results, you must respond to Additional Documentation Requests. Failure to do so may lead to investigation by the National Supplier Clearinghouse.

Third, make sure that your proof of delivery forms (a) contain all the elements required by Medicare and (b) get filled out completely before you submit your claim. This is a fundamental requirement that you have to comply with.

Fourth, make sure that you detail with specificity the medical reasons for supplying a new brace. If the medical records fail to do so and the patient has previously received a brace whose reasonable useful lifetime has not yet been exhausted, you risk a denial on the ground that the patient already received a same/similar device. The DME MAC's claim system denies these claims in an effort to prevent wrongful (i.e., fraudulent) payments, and the only way to prevail at redetermination is to be able to point to the new clinical circumstances requiring another (different) brace. 

Lastly, the detailed written order is a requirement for every DMEPOS claim. As the supplier, you are permitted to create this document in its entirety and have the physician sign and date it. This is essentially the only document that Medicare allows a supplier to create for the prescribing doctor, and not being able to produce it in response to an ADR suggests a fundamental breakdown in internal claim processes.

We will keep you apprised of further developments regarding Region D's prepayment claim reviews as information becomes available in the future.

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