LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2014-07 Results of Widespread Prepayment Review of Claims for L0631 and L0637

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LEEDerGroup.com

July 31, 2014

Results of Widespread Prepayment Review of Claims for L0631 and L0637, Lumbar-Sacral Orthoses (L11470) Historical Review Results
  • DME MAC A Medical Review continues to review Lumbar-Sacral Orthoses (L0631 and L0637) based upon results of initial findings. The initial findings covered a period from July 16, 2013 – September 27, 2013 and resulted in a Charge Denial Rate of 76.8%.
  • Current Review Results
    The DME MAC Jurisdiction A has completed the prepayment probe review of claims for Lumbar-Sacral Orthoses;
    HCPCS code L0631 is a Lumbar-Sacral Orthoses, sagittal control with rigid anterior and posterior panels, posterior extends from sacroccoccygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment.
    HCPCS code L0637 is a Lumbar-Sacral Orthoses, sagittal-cornal control with rigid anterior and posterior fram/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment. This probe was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor.
    The review involved prepayment complex medical review of 899 claims submitted by 89 suppliers. These claims were reviewed from January 13, 2014 – April 13, 2014. Responses to the Additional Documentation Request (ADR) were not received for 170 (19%) of the claims. For the remaining 729 claims, 104 claims were allowed and 617 were denied resulting in a claim denial rate of 85%. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error divided by the total allowance amount of services medically reviewed) resulted in an overall Charge Denial Rate of 83.3%.
  • Primary Reasons for Denial
    Based on review of the documentation received, the following are the reasons for denial. Note that the percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also note that claims can be denied for multiple reasons therefore the percentages of reviews may not add up to 100%:
    Detailed Written Orders Issues
    Denied claims were missing a Detailed Written Order for L0631/L0637 being billed (15%)
    Denied claims included an incomplete order (7%)
    Detailed Written Orders submitted were not legible (2%)
    Detailed Written Orders missing start date and/or signature date (4%)
    Detailed Written Orders did not list a beneficiary name (1%)
    Medical Record Documentation Issues
    Denied claims missing the clinical documentation to support medical necessity (13%)
    Denied claims due to no pertinent clinical documentation (4%)
    Clinician notes submitted show a different beneficiary than stated within the claim submitted (3%).
    Clinician notes submitted did not satisfy medical necessity. The documentation submitted did not demonstrate the treatment of an illness or injury to improve functioning of the spine or trunk on the body (17%).
    Medical documentation was not authenticated by the clinician conducting the exam (1%).
    Proof of Delivery Issues
    Denied claims were missing the proof of delivery (23%)
    Proof of Delivery included delivery tickets not having required elements (20%)
    Delivery ticket did not include signature of beneficiary or Beneficiary’s representative; unable to determine beneficiary received items billed (13%)
    Delivery ticket dates do not match shipping/received dates for items as defined within the LCD L11470 (7%)
  • Claim Examples
    As an additional educational measure, the following are actual examples of claim denials. NHIC expects these examples will assist suppliers in understanding the medical review process and the common documentation errors that occur with Lumbar-Sacral Orthoses claims:
    Example 1:
    Received: The supplier submitted a detailed written order, which includes the beneficiary’s name, specific items or components to be dispensed, treating clinician’s signature, date of clinician’s signature and start date of order; an invoice of items that were billed, which includes the manufacturer, model numbers and cost of each item; and the evaluation/assessment documentation for the item(s) billed. Clinical documentation to support medical necessity of item which includes name of beneficiary, date of appointment, and clinician’s signature.
    Missing: Proof of delivery, with all of the required elements. Claim History Verification demonstrated beneficiary had received same L0631 within the last 5 years.
    Example 2:
    Received: The supplier submitted a detailed written order, which includes the beneficiary’s name, specific items dispensed, treating clinician’s signature and date, and the start date of order. Clinical documentation was also submitted.
    Missing: Proof of delivery, with all of the required elements. The submitted clinical documentation did not support the medical necessity.
    Example 3:
    Received: The supplier submitted a detailed written order, which includes the beneficiary’s name, specific items or components to be dispensed, date of clinician’s signature and start date of order. Proof of delivery, with all of the required elements.
    Missing: Detailed Written Order is missing practitioner signature. Clinical documentation to support medical necessity of item which includes name of beneficiary, date of appointment, and clinician’s signature.
  • Next Step
    Based upon the results of initial prepayment review, DME MAC A will continue to review claims for Lumbar- Sacral Orthoses, HCPCS codes L0631/L0637.
    DME MAC Jurisdiction A performs ongoing assessment of the effectiveness of its prepayment widespread reviews. One assessment is the Compliance Improvement Program (CIP), which measures suppliers’ performance with providing complete and accurate supporting documentation and their response rate to Additional Documentation Requests (ADRs). When a supplier achieves and maintains high quality accuracy and ADR response rate over three (3) quarterly periods, the supplier will be temporarily removed from that particular widespread review. The supplier’s authorized official will be notified and provided details of this decision.
    Questions and comments can be sent to the DME MAC Jurisdiction A Provider Compliance mailbox at: dme_mac_jurisdiction_a_provider_compliance@hp.com
    Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.
  • Educational References
    NHIC provides extensive educational offerings related to the proper documentation requirements for Lumbar-Sacral Orthoses claims. Please ensure that the responsible supplier staff is aware of and references this educational material so that supporting documentation for your claims is compliant with all requirements:
    LCD for Spinal Orthoses: TLSO and LSO (L11470)
    The DME MAC Jurisdiction A Supplier Manual – Chapter 10 – additional information regarding general coverage and documentation requirements.
    Results of Prepay Probe for Lumbar-Sacral Orthoses
    CERT Documentation Checklistl