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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 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:

Updated May 21, 2024

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