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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 April 1 and June 30, 2022. The error rate for this quarter is 39.13%. 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. 18.95%
2. No medical record documentation was received. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8. 10.00%
3. The documentation does not contain a valid standard written order (SWO). Refer to Standard Documentation Requirements A55426. 10.00%
4. The treating practitioner's order, Certificate of Medical Necessity (CMN), supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to the Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9. 10.00%
5. The item was provided prior to an inpatient hospital admission or Part A covered skilled nursing facility (SNF) stay and its use began during the stay. 7.89%
6. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to the Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4. 7.37%
7. The beneficiary was in an acute care hospital or SNF on this date of service. Refer to the Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212. 6.84%
8. 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. 6.32%
9. Medical records do not support one of the four criteria for a spinal orthosis. 6.32%
10. The documentation submitted indicates the item(s) were returned by the beneficiary. 3.68%

*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:

Additional Education:

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