Ankle-Foot Orthosis (AFO) Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for AFO HCPCS codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397 and L4631 reviewed between July 1 and September 30, 2023. The error rate for this quarter is 40.56%. 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. | 21.03% |
2. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 19.56% |
3. | 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 & Standard Documentation Requirements A55426. | 16.24% |
4. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements A55426. | 7.01% |
5. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. | 6.64% |
6. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212. | 5.90% |
7. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 4.43% |
8. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 3.32% |
9. | Documentation provided in the supplier's records and the treating practitioner's medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis. | 2.95% |
10. | The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the LCD-related Standard Documentation Requirements Article A55426. | 2.21% |
*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:
- Ankle-Foot/Knee-Ankle-Foot Orthosis Documentation Checklist
- Ankle-Foot/Knee-Ankle-Foot Orthoses – Policy Article (A52457)
- Ankle-Foot/Knee-Ankle-Foot Orthosis – LCD (L33686)
- Medicare Claims Processing Manual
- Medicare Program Integrity Manual
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Updated: November 15, 2023