CGS Administrators, LLC

November 10, 2016

Status Report for Quarter 3 2016: HCPCS Code L0637 – Service-Specific Prepayment Review

The Medical Review Department of CGS, the Jurisdiction B DME MAC, began a complex service-specific prepayment review of HCPCS code L0637 (Spinal Orthoses) claims on July 1, 2016. This review is the result of data demonstrating a high claims payment error rate for this product category.

A summary report for claims reviewed between July 1, 2016 and September 30, 2016 follows:

  Current Quarter
Denial Rate 91%

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent *
1 Documentation at the time of delivery is not sufficiently detailed to include a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. 68.75%
2 Medical records from the practitioner does not document the orthosis in the plan of care along with the need for the spinal orthosis as one of the following:
  1. To reduce pain by restricting mobility of the trunk; or
  2. To facilitate healing following an injury to the spine or related soft tissues; or
  3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  4. To otherwise support weak spinal muscles and/or a deformed spine.
3 The detailed written order did not include a detailed list of all items dispensed and billed. 18.40%
4 The documentation did not include proof of delivery for the item(s) billed. 17.36%
5 The delivery slip did not include a description of items delivered. 13.89%
6 The documentation does not include medical records (not records from just the orthotist or supplier). 13.19%
7 The documentation does not include a detailed written order. 12.15%
8 The detailed written order is missing the date of the order and the start date, if start date is different from the date of the order. 9.38%
9 The medical record documentation is not authenticated (handwritten or electronic) by the author. 6.94%
10 The proof of delivery is missing the beneficiary or authorized representative signature. 3.47%

Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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