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2019 Quarterly Status Report – HCPCS Code L0450-L0651

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows: 

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8. 17.65%
2 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04. 15.69%
2 The detailed written order contains a physician/practitioner's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. Refer to Medicare Program Integrity Manual 5.2.3 & Medicare Program Integrity Manual 3.3.2.4 &Standard Documentation Requirements A55426. 15.69%
2 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. Refer to A52500. 15.69%
2 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 15.69%
6 Medical records do not support one of the four criteria for a spinal orthosis. Refer to L33790. 11.76%
7 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. Refer to A52500. 9.80%
7 The item was provided prior to an inpatient hospital admission or Part A covered skilled nursing facility stay and its use began during the stay. Refer to A55426. 9.80%
9 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual. 5.88%
10 The medical record documentation contains corrections/changes that do not comply with accepted record keeping principles. Section B of PIM 3.3.2.5. 3.92%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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