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Linda Collins Blogger

Coverage Requirements for Spinal Orthoses

Posted by Linda Collins | October 22, 2013

According to the audit results, nearly a quarter of claims under review do not meet the coverage requirements outlined in Local Coverage Decision and the Policy Article.

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.

The LCD further requires that you have product information demonstrating that the Spinal Orthoses provides control of motion in one or more planes or provides intracavitary pressure.

Finally, you must have documentation in the patients’s medical records that supports that the Spinal Orthoses 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 the “Reimbursement Downloads” link on the left side of this page. 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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