Corporate
CGS Administrators, LLC

Serving the states of MN, WI, IL, IN, OH, KY and MI

November 5, 2018

Status Report for Quarter 2 - 2018: HCPCS Code L0450-L0651

A summary report for claims reviewed between April 1, 2018 and June 30, 2018 follows:

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

The detailed written order is missing a description of the item. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426

50.00%

2

Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary.

29.41%

3

The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4

20.59%

4

The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426

8.82%

4

The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.  Refer to 100-04

8.82%

4

The detailed written order is missing the date the physician signed the order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426

8.82%

7

The detailed written order contains a physician’s signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements.  Refer to Medicare Program Integrity Manual 5.2.3 & Medicare Program Integrity Manual 3.3.2.4 & SDL A55426

5.88%

7

No medical record documentation was received.  Refer to Medicare Program Integrity Manual 3.2.3.8

5.88%

7

The medical record documentation is dated after the date of service and does not provide enough information to support that the LCD requirements were met on the date of service.

5.88%

10

Medical records do not support one of the four criteria for a spinal orthosis.

2.94%

10

The detailed written order is missing the physician’s signature. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426

2.94%

10

The detailed written order is missing the date of the order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426

2.94%

10

The physicians order, Certificate of Medical Necessity, supplier prepared statement, or the physicians attestation, by itself, does not provide sufficient documentation of medical necessity.  Refer to Medicare Program Integrity Manual 5.7

2.94%

10

The detailed written order is signed by the physician after the claim was submitted.  Refer to SDL A55426

2.94%

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

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