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CGS Administrators, LLC

Serving the states of AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV and the U.S. territories Puerto Rico and the Virgin Islands

Status Report for Quarter 3 – 2018: HCPCS Codes L0650, L0631, L0637

A summary report for claims reviewed between July 1, 2018 and September 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 Supplier documentation does not include sufficiently detailed description of the modifications necessary at the time of fitting the custom fitted orthosis to the beneficiary. 47.30%
2 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4 13.51%
3 Medical records do not support one of the four criteria for a spinal orthosis. 11.49%
4 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8 10.81%
5 The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident. Refer to 100-04 9.46%
6 Section A of the advance beneficiary notice is not properly completed. 7.43%
6 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. 7.43%
8 The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 5.41%
9 The detailed written order is missing the date of the order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426 4.73%
10 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual 4.05%

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

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