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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 January 1 and March 31, 2024. The error rate for this quarter is 30.66%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic used during ambulation. 31.49%
2. The HCPCS procedure code on the claim is not correct for the item billed. 13.19%
3. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. 13.19%
4. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 11.06%
5. The documentation does not have a valid Standard Written Order (SWO). 5.96%
6. The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic not used during ambulation. 4.26%
7. We did not receive any medical record documentation. 3.40%
8. The documentation is incomplete. 2.98%
9. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 2.55%
10. The SWO is missing a description of the item. 2.55%

*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:

Updated: May 21, 2024

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