Jurisdiction D External Breast Prosthesis Prepayment Review Findings

Earlier this week Jurisdiction D DME MAC Medical Review Department announced their findings of a widespread prepayment review of L8030. This prepayment review probe was created after the review of a Comprehensive Error Rate Testing (CERT) analysis. Much like the findings of Jurisdiction B prepayment probe of high dollar claims late last year, the overall percentage of claims denials was shockingly high and points to a overwhelming miscommunication between providers and those approving claims.

The L8030 review included 95 claims of which 68 were denied. This resulted in an overall error rate of 76%. The previous prepayment probe of high dollar claims included an error rate of 89%. After determining the high error rate, Noridian Administration Services will close the prepayment review and begin a widespread targeted review on HCPCS code L8030. Below are the reasons for the claims denials from the release:

• 22% of L8030 claims received a denial as no office notes or medical records to support medical necessity were submitted.
• 19% of L8030 claims received a denial as documentation submitted did not support medical necessity for the item requested.
• 17% of L8030 claims received a denial for invalid proof of delivery.
• 14% of L8030 claims received a denial as no documentation was received.

Documentation requirements and utilization parameters as outlined in the External Breast Prostheses Local Coverage Determination (LCD) L11569 and Policy Article A19833.

Are you tired of wondering whether the claims you submit for Medicare beneficiaries will be denied for mythical documentation issues? Visis www.speak4oandp.com to tell your story!

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