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Linda Collins Blogger

Back starts with B

Posted by Linda Collins | July 31, 2013

MAC Region B has announced it is initiating a widespread pre-payment review of Spinal Orthoses: Thoracic-Lumbar-Sacral Orthosis (TSLO) and Lumbar-Sacral Orthosis (LSO).  

Data analysis of claims from the second half of 2012 indicated an increase in TSLO and LSO claims. The MAC will randomly review claims prior to payment for compliance with the Local Coverage Decision and the Policy Article. The MAC will send an Additional Documentation Request (ADR) letter to you if it selects one of your claims for review.  You will then have a limited time to gather the supporting information and submit to the MAC. Upon receipt and review, the MAC will determine whether to forward the claim for payment or deny it.

What does this mean for you?

First, according to the LCD, you can only provide spinal orthoses if the device will

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

You must record these conditions in the patient’s medical record and confirm that the doctor does the same. Documents created by you and dated/initialed by the doctor do not satisfy this requirement! Rather, the doctor’s own notes must contain the required information

Second, as a supplier, you must provide additional documentation to Medicare or a Medicare contractor upon request. After submission but before payment, an auditor may ask for copies of your supporting documentation. Failure to provide it will result in an automatic claim denial and may put you at risk for additional audits. Respond to all requests for documentation, even if you believe your notes are insufficient.

Lastly, comply with the LCD’s requirements:

  • If you dispense an item based on a verbal order, you must have the following documentation:
    • Description of the item
    • Name of the beneficiary
    • Name of the physician
    • Start date of the order
  • Do not submit claims before obtaining a valid written order that contains:
    • Beneficiary's name
    • Detailed description of the item(s) to be dispensed (The detailed description in the written order may be either a narrative description or a brand name/model number.)
    • Treating physician's signature (Signature and date stamps are not allowed.)
    • Date the treating physician signed the order
    • Start date of the order - if the start date is different than the signature date
  • Beneficiary authorization
  • Proof of delivery
  • Product information demonstrating that the TLSO provides control of motion in one or more planes or provides intracavitary pressure
  • Documentation in the beneficiary’s medical records that supports that the TLSO was ordered for one of the following indications:
    • 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.

Taking the time to organize documents before claims submission will help you respond to prepayment audits in a timely and efficient way.

We offer additional help under “Reimbursement Resources”. Please note that we have created a Spinal Orthoses Claims Checklist to assist you in gathering the necessary documents prior to claims submission for these devices.

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com