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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 January 1 and March 31, 2024. The error rate for this quarter is 57.42%. 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 billed.	50.99%
2.	Medical records do not support one of the four criteria for a spinal orthosis.	13.86%
3.	There is not a valid handwritten or electronic signature by the author of the medical record.	13.37%
4.	The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met.	5.45%
5.	The supplier indicates the items were billed in error.	3.47%
6.	We did not receive any medical record documentation.	2.48%
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.	2.48%
8.	The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.	1.98%
9.	The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)	1.49%
10.	The beneficiary was in an acute care hospital or skilled nursing facility on this date of service.	1.49%

*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:

Updated: May 21, 2024

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Spinal Orthosis Pre-Pay Review Quarterly Status Report

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