Quarterly Results of Prepayment Review of Spinal Orthoses

DMEMAC Jurisdiction D Medical Review Department released updated results on a widespread prepayment review program for spinal orthoses HCPCS codes, L0631 and L0637. The claims probed were from July 2013 – September 2013 and included a total of 2,112 claim submissions. The examined claims continued to yield a high error/denial rate.  From the Noridian Release:

 The L0631 review involved 1,584 claims, of which 1,369 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 87%.

The L0637 review involved 528 claims, of which 453 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 86%.

Primary Documentation Errors that Resulted in Denial of Claims

  • 22% of L0631 claims received a denial as coverage criteria indicated in Spinal Orthoses LCD (L11459) was not met.
  • 17% of L0637 claims received a denial as coverage criteria indicated in Spinal Orthoses LCD (L11459) was not met.  
  • 19% of L0631 claims received a denial as the proof of delivery provided was invalid.
  • 20% of L0637 claims received a denial as the proof of delivery provided was invalid. 

For a more complete listing of the prepayment review findings, please click here.

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This entry was posted in Orthotics and Prosthetics, Prosthetist, re provider, Uncategorized and tagged , , , . Bookmark the permalink.

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