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 October 1 and December 31, 2023. The error rate for this quarter is 34.53%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 21.53% |
2. | The HCPCS procedure code on the claim is not correct for the item(s) billed. | 21.24% |
3. | 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 for All Claims Submitted to DME MACs (A55426) | 18.29% |
4. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 10.91% |
5. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 5.60% |
6. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 5.31% |
7. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212. | 3.54% |
8. | The documentation submitted is incomplete. | 2.65% |
9. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 | 2.36% |
10. | The claim was submitted with an incorrect modifier. Refer to Medicare Claims Processing Manual 100-04, Chapter 20 and Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686). | 2.06% |
*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:
- Ankle-Foot/Knee-Ankle-Foot Orthosis Documentation Checklist
- Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686)
- Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Article (A52457)
- Orthotics and Prosthetics Medical Review Resources
Updated: February 2, 2024