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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 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 50External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 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)External Website. 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 210-212External PDF. 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 3.2.3.8External PDF 2.36%
10. The claim was submitted with an incorrect modifier. Refer to Medicare Claims Processing Manual 100-04, Chapter 20External PDF and  Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686).External Website 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:

Updated: February 2, 2024

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