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 April 1 and June 30, 2024. The error rate for this quarter is 32.32%. The top ten reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The HCPCS procedure code on the claim is not correct for the items billed. | 17.70% |
2. | The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. | 16.52% |
3. | The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. | 13.86% |
4. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 10.32% |
5. | The documentation does not have a valid Standard Written Order (SWO). | 7.37% |
6. | The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. | 6.49% |
7. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. | 4.72% |
8. | We did not receive any medical record documentation. | 4.13% |
9. | The claim was submitted with an incorrect modifier. | 4.13% |
10. | Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. | 2.95% |
*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:
- 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
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: July 30, 2024