NHIC, a Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor, recently released the results of a widespread prepayment complex review of claims for lower limb prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided, showing an overall charge denial rate of 50.1%.
The review involved a prepayment complex medical review of 177 claims submitted by 114 suppliers for claims processed from January 2014 to March 2014. Of 144 claims, 111 claims were denied, resulting in a claim denial rate of 77%.
Based on review of the documentation received, reasons for claims denial included a lack of medical record documentation (36.9%); lack of prosthetist records (9%); functional level of the billed item not supported by clinical documentation (24.3%) and missing proof of delivery (7%).
DME MAC Jurisdiction A will continue a prepayment review for lower limb prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided. Suppliers who fail to respond to additional documentation requests may be referred to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.
For more information and educational references, visit http://www.medicarenhic.com/viewdoc.aspx?id=2665