Noridian Releases Results of Prepayment Review of L4360, L1970 and L1960

Jurisdiction D DME MAC has been conducting a wide ranging prepayment review of ankle/foot and knee/ankle orthosis HCPCS codes L4360, L1970 and L1960. Below is a summary of the results of the prepayment reviews for the first quarter of 2013. The average denial of claims are consistent with prior prepayment reviews done on orthotic and prosthetic L codes.

The L4360 review involved 564 claims of which 474 were denied. This resulted in an overall error rate of 84%.

The L1970 review involved 63 claims of which 53 were denied. This resulted in an overall error rate of 86%.

The L1960 review involved 109 claims of which 87 were denied. This resulted in an overall error rate of 80%.

Primary documentation errors that resulted in denial of claims:

  • 23% of L4360 claims received a denial as no proof of delivery submitted.
  • 7% of L1970 claims received a denial as no proof of delivery submitted.
  • 22% of L4360 claims received a denial as no detailed written order or dispensing order received
  • 25% of L1970 claims received a denial as the treating physician’s records don’t provide detailed documentation to support medical necessity of custom rather than prefab orthosis.
  • 22% of L1960 claims received a denial as the treating physician’s records don’t provide detailed documentation to support medical necessity of custom rather than prefab orthosis.
  • 19% of L4360 claims received a denial as documentation insufficient to support basic coverage criteria.
  • 17% of L1960 claims received a denial as documentation insufficient to support basic coverage criteria.
  • 13% of L1970 claims received a denial as documentation insufficient to support basic coverage criteria.

For a more complete analysis of the rationale behind the claims denials, please visit the Noridian website.

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