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 January 1 and March 31, 2024. The error rate for this quarter is 47.37%. 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. | 52.11% |
2. | The medical records lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 11.27% |
3. | There is not a valid handwritten or electronic signature by the author of the medical record. | 8.45% |
4. | Medical records do not support one of the four criteria for a spinal orthosis. | 7.04% |
5. | 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. | 5.63% |
6. | 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. | 4.23% |
7. | The documentation does not contain a valid Standard Written Order (SWO). | 2.82% |
8. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. | 2.82% |
9. | We did not receive any medical record documentation. | 1.41% |
10. | The documentation is incomplete. | 1.41% |
*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:
- 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)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated May 21, 2024