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Spinal Orthosis Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for lumbar sacral orthoses (LSO) HCPCS codes L0450-L0651 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 71.35%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The HCPCS procedure code on the claim is not correct for the item(s) billed. 60.49%
2. Medical records do not support one of the four criteria for a spinal orthosis. 11.73%
3. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF. 4.32%
4. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4External PDF. 3.09%
5. The documentation submitted is incomplete. 3.09%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 1.85%
7. The supplier indicates the item(s) were billed in error. 1.85%
8. The claim submitted is a duplicate to another claim processed through medical record review. 1.85%
9. 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. 1.85%
10. 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. 1.85%

*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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