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 July 1 – September 30, 2024. The error rate for this quarter is 42.99%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 29.17% |
2. | Medical records do not support one of the 4 criteria for a spinal orthosis. | 28.33% |
3. | The HCPCS procedure code on the claim is not correct for the items billed. | 24.17% |
4. | The order is missing a description of the item. | 11.67% |
5. | The documentation does not contain a valid written order prior to delivery. | 1.67% |
6. | We did not receive any medical record documentation. | 1.67% |
7. | The documentation does not contain a valid order. | 0.83% |
8. | The documentation is incomplete. | 0.83% |
9. | 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. | 0.83% |
10. | The documentation shows the beneficiary returned the items. | 0.83% |
*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 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: November 1, 2024