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Ankle-Foot Orthosis (AFO) Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for AFO HCPCS codes L1900-L1990, L2000, L2005, L2010-L2136, L4350-L4387, L4396-L4397 and L4631 reviewed between April 1 and June 30, 2024. The error rate for this quarter is 29.50%. The top ten reasons for claim denials are as follows:

Rank Reason Percent
1. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. 22.22%
2. The medical records do not confirm that the beneficiary meets the coverage criteria for an orthotic used during ambulation. 20.77%
3. The HCPCS procedure code on the claim is not correct for the items billed. 14.98%
4. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 10.63%
5. The documentation does not have a valid Standard Written Order (SWO). 6.76%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 4.83%
7. The documentation is incomplete. 3.38%
8. Documentation provided in the supplier’s records and the treating practitioner’s medical record do not support the medical necessity of a custom fabricated orthosis rather than a prefabricated orthosis. 2.42%
9. We did not receive any medical record documentation. 2.42%
10. There is not a valid handwritten or electronic signature by the author of the medical record. 1.93%

*The total percentage will be greater than 100% because some claims denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: July 29, 2024

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