December 18, 2014

DME MAC D Publishes Results of KOs Prepayment Review

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Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced the results of its widespread prepayment probe review of Healthcare Common Procedure Coding System (HCPCS) codes L-1832 (knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise); L-1833 (knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf); and L-1843 (knee orthosis, without knee joint, rigid, custom-fabricated). The review was initiated based on the results of Comprehensive Error Rate Testing (CERT) analysis and previous review results.

  • The L-1832 review involved 111 claims, of which 111 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100 percent.
  • The L-1833 review involved 100 claims, of which 99 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98 percent.
  • The L-1843 review involved 106 claims, of which 106 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100 percent.
  • The top reasons for denial are:

  • Documentation is insufficient to support that substantial modifications were made for the custom-fitted item billed.
  • The documentation does not support knee instability by examination of the beneficiary and objective description of joint laxity.
  • The documentation does not support a recent injury to or surgical procedure on the knee.
  • No documentation was received in response to the Additional Documentation Request (ADR) letter.

Based on the high error rate, NAS said it will close this probe review and begin a widespread targeted review.

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