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Status Report for Quarter 3 – 2018: HCPCS Codes L0650, L0631, L0637

A summary report for claims reviewed between July 1, 2018 and September 30, 2018 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 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. 47.30%
2 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 13.51%
3 Medical records do not support one of the four criteria for a spinal orthosis. 11.49%
4 No medical record documentation was received. Refer to Medicare Program Integrity Manual 10.81%
5 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04 9.46%
6 Section A of the advance beneficiary notice is not properly completed. 7.43%
6 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. 7.43%
8 The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 5.41%
9 The detailed written order is missing the date of the order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 4.73%
10 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual 4.05%

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

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