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David McGill Blogger

Region D Targeting K3 Feet

Posted by David McGill | July 10, 2014

In the last year MAC Region D has invested a significant amount of time reviewing claims for K3 feet - especially those using L5980 and L5981. Here's the data for each:

Overall, the data show that claim denial rates have not materially decreased over the last 9-12 months for either code in Region D, and remain very high for both codes.

What does this mean for you?

Region D will continue to scrutinize K3 claims based on these results. The identified reasons for the denials? We're looking once again at the usual suspects:

  • documentation doesn't support the selected functional level;
  • inadequate documentation that the patient will reach or matain a defined functional level within a reasonable time period;
  • no corroborating information in the physician's records;
  • inadequate proof of delivery;
  • signature requirements not met;
  • inadequate proof that replacement, as opposed to repair, was necessary;
  • no documentation that the patient is "motivated to ambulate"; and
  • the supplier failed to respond at all to Region D's Additional Documentation Request.

How do you avoid these denials? First, make sure that you have a copy of Medicare's Local Coverage Determination and comply with its requirements. Second, remember that Ossur has a service you can use - The Audit Team - that will ensure your claims are Medicare-compliant for a fixed fee per claim. In order to speak to The Audit Team, email them at [email protected].

Region D has demonstrated that it will consistently review K3 foot claims. That won't change until prepayment review claim denial rates fall significantly. Review the LCD, use The Audit Team, and turn the denial rate tide.

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]