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Linda Collins Blogger

L0631 and L0637 Audit Results

Posted by Linda Collins | May 21, 2014

MAC Region D has announced the quarterly results of an ongoing audit of Spinal Orthoses with HCPCS codes L0637 and L0631.

According to the audit results, 87% of claims under review do not meet the coverage requirements outlined in Local Coverage Decision and the Policy Article. (Claim failure rate for L0631 was 86% and the claim failure rate for L0637 was 88%)

The main reasons for claims denial include:

  • No response to MAC requests for additional documentation (ADR)
  • Coverage criteria in the LCD was not met
  • Proof of Delivery (POD) was invalid
  • The item did not have valid coding verification on PDAC

What does this mean for you?

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.

You must have documentation in the patient’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.

In all instances, the provider must obtain a signed and dated delivery slip which includes the patient’s name, delivery address, detailed description of the item(s) delivered, the quantity delivered, date of delivery and the a valid signature.

You must refer to the PDAC website to verify the Spinal Orthoses billed is listed for the HCPCS code you will bill. Many items require coding verification review by the PDAC contractor. All Spinal Orthoses products, including L0637 and L0631, must be listed on the PDAC website in order for the billed code to be valid. As noted in the LCD and related Policy Articles that include these codes, claims for these HCPCS codes will be denied if the products requiring coding verification review are not listed on the PDAC Product Classification List. You may check specific products at www.dmepdac.com.

Össur has additional resources available to you under the “Reimbursement Resources” section. Further, all Össur Spinal Orthoses products can be found on the PDAC website and the appropriate PDAC letters are on the product pages at www.ossur.com.

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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