Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of spinal orthoses L0631 and L0637.
The L0631 review involved 101 claims of which 96 were denied, resulting in an overall error rate of 96%, while the L0637 review involved 100 claims of which 80 were denied, resulting in an overall error rate of 80%.
Primary documentation errors that resulted in denial of claims for L0631 included 24% of claims not meeting Criteria 1; 23% of documentation did not support medical necessity for the item requested; 7% had invalid proof of delivery; and 12% had no documentation received.
Primary documentation errors that results in denial of claims for L0637 included 14% of claims not meeting Criteria 1; 13% documentation did not support medical necessity for the item requested; 14% had no proof of delivery submitted; and 12% did not meet billing requirements.
Based on high error rate, Noridian Administration Services will close this probe review and begin a widespread targeted review on the spinal orthoses. The Noridian Administration Services believes it is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Spinal Orthosis Local Coverage Determination L11459 and Policy Article A23846.