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Posted by Linda Collins | March 25, 2013

As we predicted in our October 15, 2012 post, Cover Your Back, Medicare has turned its auditing eye towards Spinal Orthoses. Last Friday, MAC Region A announced a widespread pre-payment review of codes L0631 and L0637. MAC A has initiated this review due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.

This announcement comes on the heels of the pre-payment review completed by MAC Region D, where they found a high percentage of claims errors due to lack of sufficient documentation, lack of medical necessity, missing proof of delivery, and erroneous claims billing for Part A (see, Severe Back Pain post, December 21, 2012)

What does this mean for you?

It appears the DME MACs will focus on physician records to justify the medical necessity for these devices. In other words, even if you receive a prescription from a physician, you will have to obtain documentation from the doctor to support the need for the orthoses. Just as we’ve seen over the past 18 months with prosthetic claims, the supporting documentation must be part of the doctor’s medical record. 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.

This means that after submission but before payment on the claim, an auditor may come to you and ask for copies of the supporting documentation. If you do not have this in your files the claim will be denied.

A summary of requirements outlined in the LCD is listed here:

  • 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.

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