Spinal Orthosis Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for lumbar sacral orthosis (LSO) HCPCS codes L0450-L0651 reviewed between October 1 and December 31, 2022. The error rate for this quarter is 50.67%. 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. | 37.29% |
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. | 19.95% |
3. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 10.45% |
4. | The medical records lack sufficient information to determine if the beneficiary's condition met medical necessity coverage criteria. | 8.08% |
5. | The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. | 5.94% |
6. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. | 3.09% |
7. | 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. | 3.09% |
8. | The author did not authenticate (handwritten or electronic) the medical record documentation. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. | 1.90% |
9. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 1.66% |
10. | The item was provided prior to an inpatient hospital admission or Part A covered SNF stay, and its use began during the stay. | 1.19% |
*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 Spinal Orthoses: TLSO and LSO – Policy Article (A52500)
- Local Coverage Determination for Spinal Orthoses: TLSO and LSO (L33790)
- 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: