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Linda Collins Blogger

Documentation of Custom Fit Spinal Bracing

Posted by Linda Collins | April 27, 2016

NHIC, Region A DME MAC, recently released results of an audit on spinal orthoses billed with HCPCS L0631 and L0637. The audit showed an overall claim denial rate of 86%.

Main reasons for denials of the claims included:

  • Failure to respond to the Additional Documentation Request (ADR) letter.
  • Missing Detailed Written Order (DWO.)
  • Missing Proof of Delivery (POD)

The largest of claims denied were due to incomplete/invalid clinical documentation. In this case, the medical record documentation did not support substantial modifications made to the custom fit braces.

Most spinal braces have two code options when billing the claim. The Off the Shelf code is used when a prefabricated brace is given to the patient and it requires minimal self-adjustment to fit. The Custom Fit code is used when, at the time of delivery, substantial modifications are performed by a person with expertise and these modifications are documented.

The claims examples provided by NHIC indicate the medical documentation did not have details on the substantial modifications made to the brace at the time of delivery. Using terms such as "brace was fit" is not enough documentation. The Local Coverage Determination states custom fit braces are those requiring substantial modification for fitting at the time of delivery. Substantial modifications include trimming, bending, molding, or other alterations beyond minimal self-adjustment.

What does this mean for you?

If you are billing custom fit codes be sure to fully document the substantial modifications done to the brace and the reason for the modification. If you are not providing modifications, consider billing the off the shelf code for the same brace.  At this time, the Medicare allowable is the same for custom fit and off the shelf.

For your reference, a list of the products with off the shelf and custom fit coding options may be downloaded from the "reimbursement resources" tab on the left hand side of the Össur R&R page.

You may read the results of the audit, including claims examples, at

Össur R&R

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

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]