Noridian Administrative Services, LLC, the Jurisdiction D DME MAC has recently released results of two ongoing widespread pre-payment reviews; one for diabetic shoes described by A5500 and the other for AFOs described by codes L4360, L1960, and L1970. All reported results involve claims that were reviewed between December, 2012 and March 2013.
For diabetic shoes described by A5500, the overall error rate was reported as 92%. A total of 2,240 claims were reviewed with 1,984 claims denied. The most common reason for claim denial (26%) was lack of documentation in the medical record that supported one of the 6 conditions secondary to diabetes that must be present in order to warrant Medicare coverage of diabetic shoes. Other reasons for claim denial included lack of documentation of a visit with the certifying physician (20%), no documentation received to support medical necessity of the shoes (11%), and lack of documentation of an in person fitting and evaluation visit with the supplier of the shoes (7%). Based on the overall claim denial rate of 92%, Jurisdiction D has announced that the widespread pre-payment review for A5500 will continue.
For AFOs described by L4360, L1960, and L1970, the reported error rates were 84%, 86%, and 80% respectively. For L4360, the majority of denials (23%) were due to missing proof of delivery documentation with another 22% denied due to a lack of a dispensing and/or detailed written order. For L1960 (22%) and L1970 (25%), the majority of denials were due to lack of documentation in the physician’s records supporting the use of a custom orthoses rather than a prefabricated orthosis. An additional 21%-22% of claims for L1960 and L1970 were denied due to a lack of documentation supporting one of the five criteria necessary for selection of a custom fabricated orthosis. As a result of the overall high denial rate, Jurisdiction D has announced that the widespread pre-payment review for L4360, L1960, and L1970 will continue.