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Linda Collins Blogger

Audit Results for Back Braces

Posted by Linda Collins | November 10, 2014

NHIC Corp, Region A DME MAC, released audit results from its widespread pre-payment review of claims for L0631 and L0637. The results, which covered the time frame from January 13 - April 13, 2014, show an overall charge denial rate of 83.3% for spinal orthoses claims. As a result, the audits will continue.

The report lists three main reasons for denial:

  • Missing Detail Written Order (DWO)
  • No clinical documentation to support medical necessity of the brace
  • Proof of delivery missing

In addition to the above mentioned errors, 41% of the claims were denied for a lack of response to the request for additional documentation.

What does this mean for you?

First, you must be familiar with the Local Coverage Decisions and Policy Articles, which you can find here: Medicare Coverage Database. The LCD provides detailed information about coverage and documentation requirements. Under the “General Information” section at the end, you will find a detailed listing of the forms needed to submit a claim.

Second, when you receive a request from an auditor for additional documentation, you must respond within the timeframe indicated. Failure to respond will result in an automatic denial of the claim, forfeit your rights to an appeal, and possibly get your practiced referred for further auditing. Respond, even if you do not have adequate documentation. Respond, even if the claim will not meet the coverage criteria. Respond.

Third, review your Detailed Written Orders and Proof of Delivery. Medicare requires both of these documents to be completely and accurately filled out and legibly signed and dated in order for the claim to be valid.

Finally, make sure you and the prescribing physician thoroughly document the need for the spinal orthosis. According to the LCD, a spinal orthosis is covered when one or more of the following conditions exist:

  • To reduce pain by restricting mobility of the trunk; or
  • To facilitate healing following an injury to the spine or related soft tissues; or
  • To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  • To otherwise support weak spinal muscles and/or a deformed spine.

The clinical documentation that will be reviewed during an audit needs to demonstrate the existence of one or more of these conditions.

Don’t get caught with your back up against a wall. Know the coverage criteria, respond to requests, and have the appropriate forms.

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