July 3, 2014

Jurisdiction D Releases Results of L-5980 Prepayment Review

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Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has released quarterly results for its service-specific review of lower-limb prosthesis Healthcare Common Procedure Coding System (HCPCS) code L-5980 (all lower extremity prostheses, flex foot system). The review involved 39 claims from February through May 2014, of which 33 were denied. Based on dollars, this resulted in an overall potential improper payment rate of 84 percent. The top denial reasons were as follows:

  • Documentation did not support the functional level billed on the claim.
  • Documentation did not support the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
  • No documentation was received in response to the Additional Documentation Request (ADR) letter.
  • Signature requirements were not met.

Based on the results of this review, NAS said it will continue with the prepayment service-specific review.

NAS has provided the following links to educational material so suppliers can familiarize themselves with the documentation requirements and utilization parameters as outlined in the Lower Limb Prostheses Local Coverage Determination (LCD) L11453 and Policy Article A25367. Suppliers can also review a specific policy Documentation Checklist for Lower Limb Prostheses on the NAS website.

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