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David McGill Blogger

Orthosis LCD Updates

Posted by David McGill | May 06, 2015

​The DME MACs have updated the LCDs for AFO's/KAFO's, knee orthoses and spinal orthoses. There are 4 key changes you need to know:

  1. The MACs have added language making clear that Medicare does not automatically assume payment for an orthosis that was covered before the beneficiary became eligible for the Medicare FFS program. Rather, the supplier must establish that the patient meets all relevant coverage criteria when delivering an orthosis - even if it is the same orthosis previously covered by the beneficiary's previous insurer - in order to get reimbursed.
  2. The update includes changes to the LCD to bring it in line with the revised guidance on OTS v. custom-fit items discussed at length in Össur R&R here​.
  3. The MACs have revised the language regarding orthotic repairs to make clear that (a) you do not need a new prescription for repairs, but (b) the physician must document that the item remains reasonable and necessary and (c) the physician or supplier must document that the repair itself is reasonable and necessary. 
  4. When billing an unlisted procedure code for an orthosis covered by the LCD, "all of the following information must accompany the claim": (a) manufacturer's name; (b) product name, model name and model number; (c) narrative description of the item (for custom-fabricated items); and (d) justification of patient's medical necessity for the item.

What does this mean for you?

The LCD's for AFO's/KAFO's, knee orthoses and spinal orthoses set forth Medicare's coverage requirements for each type of device. With these revisions, now is the time to confirm that your claims/billing processes are aligned to ensure that: 

  • You satisfy all Medicare coverage requirements for these orthoses, even if the patient previously received exactly the same brace from a different payer before joining Medicare's FFS program.
  • You (1) have a physician's prescription that specifies whether the device is prefabricated or custom-fabricated and (2) if the device is a prefabricated, custom-fit orthosis, you document both the substantial modification performed at the time of delivery and the certified orthotist​ or person with equivalent specialized training who performed those modifications.
  • For orthotic repair claims, you have documentation from the physician substantiating that the orthosis remains reasonable and necessary and documentation in your or the physician's records additionally showing that the repair itself is reasonable and necessary.
  • Any claims for these types of orthoses that include an LX999 code include all of the required manufacturer and product information.
The LCD's are your blueprint for how to get paid for the care you provide. Ignore them at your peril!
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