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Linda Collins Blogger


Posted by Linda Collins | August 06, 2013

On January 1, 2013, all four DME MACS announced an update to the Spinal Orthoses Local Coverage Decisions. (“Updates to Spinal Orthoses LCDS effective January 1, 2013”.) After the changes, Region D initiated a widespread pre-payment review of claims for L0631 and L0637. The second quarter results show an overall error rate of 85% for spinal orthoses claims. As a result, the audits will continue.

The report lists three main reasons for denial:

  • Coverage criteria not met
  • No documentation received in response to request
  • Proof of delivery missing or invalid

What does this mean for you?

First, you must be familiar with the Local Coverage Decisions and Policy Articles. (see “Back to Back” March 25, 2013, “The Heat is Back” May 28, 2013 and “Back Starts with B” July 31, 2013). The Spinal Orthoses Claims Checklist available under the Reimbursement Resources tab on the left is a great resource for you and your staff.

Second, when you receive a request from an auditor for additional documentation, you must respond within the timeframe indicated. Failure to respond will result in an automatic denial of the claim, forfeit your rights to an appeal, and possibly get your practiced referred for further auditing. Respond, even if you do not have adequate documentation. Respond, even if the claim will not meet the coverage criteria. Respond.

Third, review your Proof of Delivery process. Medicare requires a proof of delivery (POD) signed and dated by the patient. The POD must include:

  • The quantity delivered
  • A detailed narrative description of the item
  • The brand name (manufacturer)
  • The model name or number (if applicable), and
  • The serial number (if available)

Don’t get caught with your back up against a wall. Know the coverage criteria, respond to requests, and have a valid proof of delivery.

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