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David McGill Blogger

Small Sample, Bad Results

Posted by David McGill | August 14, 2014

MAC Region D released the results for its review of L5987 claims from March through June of this year. The review encompassed only 18 claims, 17 of which the MAC denied for a 94% claim denial rate. The top denial reasons listed by Region D were:

  • Documentation didn't support the billed functional level;
  • Inadequate proof that the patient would reach or maintain a defined functional state in a reasonable period of time;
  • Documentation didn't establish the patient's motivation to ambulate;
  • No response received to request for additional information; and
  • Documentation didn't support the need for a replacement item.
What does this mean for you?

Aside from the fact that Region D announced it will continue its prepayment review of L5987 based on these results, the not-very-satisfactory answer to this question is that it's hard to tell. The small sample size makes it difficult to draw broad conclusions. When Region D last published L5987 results in March, the claim failure rate was 82%, but the sample size was a more respectable 99 claims.

The most we can say is that (a) no one can view a 17 out of 18 failure rate as a good thing, and (b) the identified failures continue to be basic, "claims 101"-type issues specifically listed in the Local Coverage Determination's requirements. We therefore recommend that you

  1. Review the LCD​ and make sure that all your L5987 claims comply with its required elements;
  2. Download Ossur's Lower Limb Prosthesis Documentation Checklist and use it; and
  3. If you're still having problems, consider using our strategic partner, The Audit Team, which you can contact at sgreene@theauditteam.com.

The only way to make prepayment claim reviews eventually go away is to improve the claim error and payment rates. You must meticulously and relentlessly ensure that both your documentation and the physicians' records comply with Medicare's coverage requirements. Taking the time to run this gauntlet before filing the claim will save you enormous amounts of time and energy later.

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