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, 2023. The error rate for this quarter is 56.99%. 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. | 52.00% |
2. | Medical records do not support one of the four criteria for a spinal orthosis. | 10.40% |
3. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 6.40% |
4. | The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. | 6.40% |
5. | The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. | 6.40% |
6. | 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 for All Claims Submitted to DME MACs (A55426). | 5.60% |
7. | The claim submitted is a duplicate to another claim processed through medical record review. | 4.80% |
8. | 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. | 4.00% |
9. | The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 1.60% |
10. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. | 0.80% |
*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:
- Orthotics and Prosthetics Medical Review Resources
- Spinal Orthoses Documentation Checklist
- Spinal Orthoses: TLSO and LSO – LCD (L33790)
- Spinal Orthoses: TLSO and LSO – Policy Article (A52500)
Updated: February 2, 2024