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Spinal Orthosis Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for lumbar sacral orthosis (LSO) HCPCS codes L0450-L0651 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 56.99%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The HCPCS procedure code on the claim is not correct for the item(s) billed. 52.00%
2. Medical records do not support one of the four criteria for a spinal orthosis. 10.40%
3. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 6.40%
4. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4External PDF. 6.40%
5. The records do not support that the person who did the custom fitting for the orthosis has the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. 6.40%
6. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Section 50 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 5.60%
7. The claim submitted is a duplicate to another claim processed through medical record review. 4.80%
8. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212External PDF. 4.00%
9. The documentation does not include a valid face-to-face encounter that meets the requirements as outlined in the Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 1.60%
10. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF. 0.80%

*The total percentage will be greater than 100% because some claims were 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 represent an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: February 2, 2024

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