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Ankle-Foot Orthosis (AFO) Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for AFO HCPCS codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397, L4631 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 32.87%. 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 billed. 22.64%
2. The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic used during ambulation. 19.15%
3. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. 14.18%
4. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 9.45%
5. The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic not used during ambulation. 7.71%
6. The documentation does not have a valid Standard Written Order (SWO). 6.47%
7. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 4.98%
8. There is not a valid handwritten or electronic signature by the author of the medical record. 2.99%
9. The documentation submitted is incomplete. 2.49%
10. We did not receive any medical record documentation. 2.24%

*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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