Jurisdiction D DME MAC Publishes Results of Pre-Payment Review of Ankle Foot Orthoses, Knee Orthoses, and Spinal Orthoses


Noridian, who serves as the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has released the most recent quarterly results of its ongoing pre-payment review of claims for several codes.

For AFOs described by HCPCS codes L1960, L1970 and L4360: from December 2015 through March 2016, a total of 1008 claims were reviewed; 855 of which were denied. This error rate varied for each code. The L1960 had an error rate of 69%, the L1970 had an error rate of 70%, and the L4360 had an error rate of 99% (484 out of 488 claims were denied). Based on these results Noridian will continue its pre-payment reviews for codes L1960, L1970 and L4360.

The DME MAC noted that common denial reasons included a lack of proof of delivery documentation, failure to include documentation to show “substantial” modifications were made to the custom fitted item (L4360), documentation was not received in response to the ADR, and insufficient documentation to establish a need for a custom fabricated item (L1960 and L1970). You may view the full results of the quarterly review here.

Noridian has also released the most recent results of its ongoing pre-payment review of claims for L1833 (knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf). From September 2015 through December 2015, a total of 627 claims were reviewed, 607 of which were denied for an overall claim error rate of 96%. Noridian noted that claims were denied due to a failure to respond or a late response to additional documentation requests (which will result in an automatic denial), the submission of an invalid proof of delivery, a missing/incorrect ICD-10 code, and documentation that did indicate the patient is ambulatory (as sometimes required by policy). You may view the full results of the review here. Based on the results, Noridian will continue its pre-payment review for code L1833.

For spinal orthoses described by HCPCS codes L0631 and L0637, from December 2015 through March 2016, a total of 291 claims were reviewed and 492 were denied, a denial rate of 99% for L0631 and 94% for L0637.

The DME MAC provided the following five top reasons for why the claims were denied: Submitted documentation didn’t identify the modifications made for the custom fitted brace; Documentation was not submitted in response to the ADR request; Missing or invalid proof of delivery; Documentation didn’t meet basic coverage criteria; Brace provided didn’t have a PDAC coding verification (required by policy). Based on the results Noridian will continue its pre-payment review for codes L0631 and L0637. You may view the full results of the review here.