Skip to Main Content

Print | Bookmark | Font Size: + |

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, L4631 reviewed July 1 – September 30, 2024. The error rate for this quarter is 30.42%. 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 items billed. 27.44%
2. The medical records do not confirm that the coverage criteria have been met for an orthotic used during ambulation. 22.74%
3. No medical record documentation was received. 10.83%
4. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. 9.75%
5. The documentation does not have a valid order. 9.39%
6. The claim was submitted with an incorrect modifier. 2.89%
7. 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. 2.53%
8. The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.  2.53%
9. The medical records do not confirm that the coverage criteria have been met for an orthotic not used during ambulation. 2.17%
10. 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. 2.17%

*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: November 5, 2024

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved