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Linda Collins Blogger

Cover Your Back

Posted by Linda Collins | October 15, 2012

Last week the OIG released their proposed Work Plan for 2013, which included several items related to the DMPOS industry ( ). One issue relates to the cost of Medicare payments for back orthoses compared to supplier acquisition costs. The OIG announced they will compare the actual reimbursement amounts for products billed using L0631 to supplier invoice amounts. The OIG states that it believes the actual purchase price may be well below the reimbursement amount.

What does this mean?

First, it is likely that you will receive requests for copies of invoices for spinal orthoses. The OIG will expect you to have these in your files and make them available as needed.

Second, even though nothing has been announced, this action by the OIG may cause other auditing agencies, such as RACs, to pursue spinal orthoses claims as an issue.

What can you do?

Make sure you are purchasing your products from a reputable source and that you keep all invoices on file. Educate your staff about the process for obtaining and filing supplier invoices. Also make sure you staff is aware of possible requests from the OIG for copies of the invoices. Any requests should be responded to within the time frame indicated.

Since 2010 it has been a requirement that any spinal orthoses billed have a PDAC letter. Make sure the spinal orthoses you dispense have a manufacturers’ PDAC letter and that you are billing the code listed in that letter by the PDAC. It is a good idea to check the PDAC website to make sure the product is listed and the model numbers you are using are assigned to the code you are billing. (

Take this opportunity to review the Local Coverage Decision (LCD) and Policy Article for Spinal Orthoses. The Policy Article defines a spinal orthoses as a device with the following characteristics:

  1. Used to immobilize the specified areas of the spine.
  2. Intimate fit and generally designed to be worn under clothing.
  3. Not specifically designed for patients in wheelchairs.

The LCD states that a spinal orthoses is covered when there is documentation to support the orthosis was ordered one of the following indications:

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

Finally, there are guidelines about spinal orthoses used at an inpatient or SNF facility. Payment for a spinal orthosis delivered to a patient in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:

  1. The orthosis is medically necessary for a patient after discharge from a hospital or Part A covered SNF stay; and
  2. The orthosis is provided to the patient within two days prior to discharge to home; and
  3. The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the patient to take home.

So, take a load off your BACK and familiarize yourself with the utilization and billing requirements now so you do not find your BACK against the wall in the future.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

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