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David McGill Blogger

Region D Focusing on Spinal Orthoses

Posted by David McGill | April 15, 2016

Region D (Noridian) has announced that it is initiating a "service specific prepayment probe review" of virtually every spinal orthotic L code:

L Code ​Short Description
​L0450​Tlso flex trunk/thor pre ots
L0452​Tlso flex custom fab thoraci
​L0454​Tlso trnk sj-t9 pre cst
​L0455​Tlso flex trnk sj-t9 pre ots
​L0456​Tlso flex trnk sj-ss pre cst
​L0457​Tlso flex trnk sj-ss pre ots
​L0458​Tlso 2mod symphis-xipho pre
​L0460​Tlso 2 shl symphys-stern cst
​L0462​Tlso 3mod sacro-scap pre
​L0464​Tlso 4mod sacro-scap pre
​L0466​Tlso r fram soft ant pre cst
​L0467​Tlso r fram soft pre ots
​L0468​Tlso rig fram pelvic pre cst
​L0469​Tlso rig fram pelvic pre ots
​L0470​Tlso rigid frame pre subclav
​L0472​Tlso rigid frame hyperex pre
​L0480​Tlso rigid plastic custom fa
​L0482​Tlso rigid lined custom fab
​L0484​Tlso rigid plastic cust fab
​L0486​Tlso rigidlined cust fab two
​L0488​Tlso rigid lined pre one pie
​L0490​Tlso rigid plastic pre one
​L0491​Tlso 2 piece rigid shell
​L0492​Tlso 3 piece rigid shell
​L0621​Sio flex pelvic/sacr pre ots
​L0623Sio rig pnl pelv/sac pre ots
​L0625​Lo flex l1-below l5 pre ots
​L0626​Lo sag rig pnl stays pre cst
​L0627​Lo sag ri an/pos pnl pre cst
​L0628​Lso flex no ri stays pre ots
​L0629​Lso flex w/rigid stays cust
​L0630​Lso r post pnl sj-t9 pre cst
​L0631​Lso sag r an/pos pnl pre cst
​L0632​Lso sag rigid frame cust
​L0633​Lso sc r pos/lat pnl pre cst
​L0634​Lso flexion control custom
​L0635​Lso sagit rigid panel prefab
​L0636​Lso sagittal rigid panel cus
​L0637​Lso sc r ant/pos pnl pre cst
​L0638​Lso sag-coronal panel custom
​L0639​Lso s/c shell/panel prefab
​L0640​Lso s/c shell/panel custom
​L0641​Lo rig pos pnl l1-l5 pre ots
​L0642​Lo sag ri an/pos pnl pre ots
​L0643​Lso sag ctr rigi pos pre ots
​L0648​Lso sag r an/pos pnl pre ots
​L0649​Lso sc r pos/lat pnl pre ots
​L0650​​Lso sc r ant/pos pnl pre ots
​L0651​Lso sag-co shell pnl pre ots​

What does this mean for you?

Expect your payment cycles in Region D for claims involving the above codes to become longer. Noridian initiates a probe review by sending you an Additional Documentation Request. You will not get paid until you respond to this request and provide information showing that you have complied with Medicare's requirements. 

If you do not respond to the ADR within 45 days, Noridian will deny your claim. In addition, failure to reply to an ADR could lead to the DME MAC - in this case Noridian - referring you to the National Supplier Clearinghouse, which has the authority to revoke your Medicare billing privileges.

Noridian has flagged in its announcement what the ADR's will focus on: 

  • ​Treating physician's dispensing and written order
  • Dispensing order (if item is dispensed based on a dispensing order)
  • Patient's medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided are reasonable and necessary
  • Justification to support the custom fitted or off the shelf orthosis code billed (if applicable)
  • Proof of delivery
  • The Advance Beneficiary Notice (if applicable)
  • Reason for replacement (if applicable)
  • Any other supporting documentation​

​In order to navigate these probe reviews as quickly and efficiently as possible, you must therefore (1) ensure that your records for claims involving any of the listed codes contain the bulleted information, above, and (2) prepare for delays in payment by ensuring that you have the liquidity to bridge the gap between delivery of the item and post-probe-review payment.

Region D has historically reported on its orthotic prepayment review results on a regular basis. We will keep you apprised of those results if and when they become available.

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