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Linda Collins Blogger

New Name, Same Game

Posted by Linda Collins | March 18, 2013

Medicare has given a new name to the Recovery Audit Contractors (RACS). Now known as Recovery Auditors, their mission is to identify and reduce Medicare improper payments made on claims of health care services provided to Medicare beneficiaries. There are four Recovery Auditors, aligned with the four DME MACs.

Click the link below to get contact information for each Recovery Auditor.

The Recovery Auditors research potential claims issues to audit. Once an RA identifies an issue and has approval from Medicare, the issue is posted on the website. Issues may cover inpatient hospital stays, diagnostic procedures, or outpatient surgeries. Each of the four RAs lists its own issues, but over time they tend to follow each other.

Currently, there are only a few RA issues posted that impact the O&P industry. Here is a brief review of the current posted issues for orthotics:

Knee Orthosis Bundling - Payments for knee orthoses additions, as specified in the LCD for Knee Orthoses,  are bundled into the payment for specific base knee orthoses, and should be recouped if paid separately.

What does this mean to you? Add-on codes are not typically separately payable for knee braces. If the base code is medically necessary, certain add on codes may be considered for payment per the chart below:

Code      Addition Codes - Eligible for Separate Payment

L1810     None

L1820     None

L1830     None

L1831     None

L1832     L2397, L2795, L2810

L1836     None

L1843     L2385, L2395, L2397

L1845     L2385, L2395, L2397, L2795

L1847     None

L1850     L2397

DMEPOS while inpatient -The Medicare DMEPOS benefit applies only to items that a beneficiary uses in his or her home. Medicare will not make separate payment for DMEPOS when a beneficiary receives treatment at an institutional provider (e.g., hospital). The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.

What does this mean to you? You can bill Medicare for an item you provide on an outpatient basis or within 48 hours of discharge from an institution when the item is for exclusive home use. If the item is to be used inpatient, the facility is responsible for payment to you for the service and you may not separately bill Medicare for that. If you do, Medicare considers it unbundling.

Spinal Orthoses -Thoracic-Lumbar-Sacral Orthosis and Lumbar-Sacral Orthosis must meet basic coverage criteria, whether at initial purchase or at any point during a rental period as outlined in CMS Publications, the Local Coverage Determination (LCD) for Spinal Orthoses: TLSO and LSO. RA’s will review medical documentation to determine that services were reasonable and necessary.

What does this mean to you? The signed order must have a diagnosis that establishes medical necessity. According to guidelines:

A thoracic-lumbar-sacral orthosis (L0450-L0492), lumbar orthosis (L0625-L0627) or lumbar-sacral orthosis (L0628-L0640) is covered when it is ordered for 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.

This information will be validated by medical record documentation, most likely from the orthotist and the ordering physician.

Learn to play the game and win by keeping yourself informed of changes in RA issues. For more assistance check the “Useful Resources” link on the left for a variety of checklists and guides.

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]