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 July 1 – September 30, 2024. The error rate for this quarter is 42.86%. 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 items billed. | 29.59% |
2. | The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic used during ambulation. | 18.93% |
3. | The documentation does not have a valid written order. | 13.61% |
4. | We did not receive any medical record documentation. | 6.51% |
5. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 6.51% |
6. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. | 5.33% |
7. | The supplier billed the item in error. | 4.73% |
8. | The documentation does not have a valid written order prior to delivery. | 2.96% |
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. | 2.37% |
10. | The order is missing a description of the item. | 2.37% |
*The total percentage will be greater than 100% because some claims 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 be 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 Orthosis LCD (L33686)
- Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Article (A52457)
- Orthotics and Prosthetics Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: November 1, 2024