Ankle-Foot Orthosis (AFO) Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for AFO HCPCS codes L1902, L1906, L1932, L1971, L2114, L4360, L4361, L4386, L4387, L4396, and L4397 reviewed between October 1 and December 30, 2022. The error rate for this quarter is 44.75%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The HCPCS procedure code on the claim is not correct for the item(s) billed. | 27.74% |
2. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 and Standard Documentation Requirements A55426. | 27.40% |
3. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 15.07% |
4. | The medical records lack sufficient information to determine if the beneficiary's condition met medical necessity coverage criteria. | 11.30% |
5. | The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. | 3.42% |
6. | The beneficiary was in an acute care hospital or skilled nursing facility (SNF) on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212. | 2.74% |
7. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 2.40% |
8. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. | 1.71% |
9. | The claim HAD an incorrect modifier. Refer to Claims Processing Manual 100-04, Chapter 20 & LCDs. | 1.37% |
10. | The claim is a duplicate to another claim billed. | 1.37% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Local Coverage Article for Ankle-Foot/Knee-Ankle-Foot Orthoses – Policy Article (A52457)
- Local Coverage Determination for Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686)
- Orthotics and Prosthetics Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Medicare Claims Processing Manual
- Medicare Program Integrity Manual
Additional Education: