DME MAC A releases results of prepayment review for lower limb prostheses

NHIC, Corp., a Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC A), released the results of a widespread prepayment complex review of lower limb prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided, which resulted in a charge denial rate of 66%.

The review included 141 claims submitted by 97 suppliers that were processed between December 2012 and February 2013. Requests for additional documentation were not received for 19 (13%) of the claims, and of the remaining 122 claims, 94 were denied, resulting in a claim denial rate of 77%.

The reasons for denials included lack of medical record documentation (30%), missing evaluation/assessment documentation (4%), clinical documentation that did not justify the functional level of the billed item (32%) and a lack of proof of delivery (12%).

Based on the results of the prepayment review, DME MAC A will continue to review claims for lower limb prostheses HCPCS codes billed with a K3 functional level modifier. NHIC also emphasized that suppliers who did not respond to Additional Documentation Requests could be referred to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.

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