New Audit Issue: Spinal Orthosis

Performant Recovery, Region 5 DMEPOS recovery auditor, has posted a new audit issue effective January 1, 2019. The issue is "Spinal Orthosis with the Reasonable Useful Lifetime (RUL.) The details indicate there may be audits on claims for more than one back brace issued within the RUL. The RUL of all spinal orthoses is five years. The HCPCS codes under review are L0627, L0631, L0637, L0642, L0648 and L0650.

What does this mean for you?

First, if you have submitted a claim to Medicare for one of these codes within the past three years, the claim may be subject to audit. If you do receive an Additional Documentation Request letter from Performant Recovery, be sure to respond with all supporting documentation.

Second, going forward be sure to check for same and similar devices delivered to a patient prior to providing a back brace. You may check to see if the patient has had a back brace within the past five years here:

Noridian Medicare Portal (NMP) for Region A and D.

myCGS web portal for Region B and C.

If the patient has been provided a same or similar device, you may use an ABN and make the patient financially responsible for the brace.

More information about Spinal Braces, including documentation requirements, can be found in the Local Coverage Determination.