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Linda Collins Blogger

Back Brace Audit Results

Posted by Linda Collins | February 09, 2016

NHIC, DME MAC, Region A, recently posted results of a pre-payment audit for HCPCS codes L0631 and L0637. These LSO codes describe a lumbar-sacral orthosis that has been trimmed, bent, molded, assembled or otherwise customized to fit a specific patient by someone with expertise. The audit covered 1,511 claims from 398 suppliers processed through September 2015 to November 2015. Overall, there was a 98% claims denial rate.

When a claim is selected for pre-payment review, an Additional Documentation Request (ADR) letter is sent to the supplier. The supplier typically has 45 days from the date of the letter to respond with all the appropriate documentation. The auditor then reviews the documents against the coverage criteria outlined in the relevant Local Coverage Determination (LCD) and Policy Article.  In the case of this audit, 25% of the suppliers did not respond to the ADR. This means 25% of the suppliers did not provide the supporting claims documentation and, therefore, received an automatic denial for the claim.

Additional denial reasons included:

  • Detailed Written Order (DWO) not provided
  • Illegible DWO
  • DWO missing the beneficiary's name
  • DWO did not include description of LSO provided
  • No clinical documentation provided to support medical necessity of the LSO
  • Medical documentation was not signed/authenticated by clinician
  • Medical documentation does not support medical need for a custom fit brace
  • Proof of Delivery (POD) not provided
  • Missing beneficiary signature on POD
  • Date of Service (DOS) does not match delivery date
  • POD does not specific brace delivered

What does this mean for you?

Always respond to all ADRs within the time frame specified. Submit your medical records, DWO/prescriptions and POD to the requesting auditor.

NHIC has indicated that due to the high denial rate they will continue auditing LSO claims. If you are in Region A be sure to review the LCD and Policy Article. Follow the guidance given on documentation, DWOs and PODs. If you are providing a custom fit brace, document the modifications done to the brace at time of delivery. If you are not modifying the brace, consider providing and off the shelf brace and bill using codes L0648 and L0650.

If you are in Region B, C, or D, the above advice is still appropriate. The MACs are auditing claims with particular attention to custom fit codes.

To review the full audit results, go to You may download a list of the orthoses which have both an Off the Shelf and Custom Fit code under the "Reimbursement Resources" section on the left side of the page.


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