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David McGill Blogger

Region D Spinal Orthoses Claim Review Results

Posted by David McGill | May 18, 2017

Region D (Noridian) has published the latest results in its ongoing prepayment claim review ​for spinal orthoses claims submitted between December 2016 - March 2017 involving codes L0631 and L0637. Here's what you need to know:

  • The claim denial rate for the 105 claims involving L0631 was 98%;
  • The claim denial rate for the 135 claims involving L0637 was 96%.
  • The top reasons for denial were:
    • documentation failed to support the criteria for a "custom fit" orthosis;
    • suppliers failed to respond to the ADR request;
    • documentation failed to show that the device provided was PDAC-verified; and
    • documentation lacked Proof of Delivery.

This continues a consistent trend of high claim denial rates for these L-codes stretching back to August, 2014:

Spinal Data.png

What does this mean for you?

If you feel like you have read this kind of summary from us before, you have. We see the same issues coming up again and again in these prepayment claim review reports from the DME MACs. We summarize each of the four issues listed above briefly for you again in the following paragraphs.

Issue 1: Failure to Satisfy "Custom-Fit" Criteria. The only time you should be billing an orthosis as a "custom fit" device is if (1) substantial modification of the brace occurs at the time of delivery, and (2) the fitting at delivery requires a certified orthotist or person with equivalent training to fit the brace on the patient. If you cannot satisfy both of these requirements, you should be billing the spinal orthosis using the applicable off-the-shelf code.

Issue 2: Failure to Respond to the ADR Request. We have written about this repeatedly in the past: responding to an Additional Documentation Request from the MAC is not optional. If you fail to answer an ADR not only will your claim get denied, the MAC may refer your company to the National Supplier Clearinghouse, which has the power to revoke your Medicare billing privileges. We cannot say it simply enough: every time you get an ADR request - even if you do not have the documentation requested - respond!

Issue 3: Lack of PDAC Verification. Any claim you submit for a spinal orthosis that has not been verified by PDAC will get denied. If you are not sure whether the specific brace you have selected has been PDAC-verified, you can search the PDAC list of verified products here. The only thing you need to do in order to satisfy this requirement is (a) make sure the brace you deliver is listed on the PDAC's website, and (b) print out a copy of the PDAC webpage showing that the item listed there is the same as the one you gave to the patient.

Issue 4: No Proof of Delivery. Folks - if you can't prove that you delivered the device to the patient on the day you delivered it you are non-compliant with Medicare claim requirements. It doesn't get any simpler than this. Whenever the patient receives an orthosis from your company, they (or their guardian/representative) must sign and date a document that clearly spells out what it is that they received, and the information on that form must match the information submitted with your claim.


Based on these results, Noridian has announced that it will continue its prepayment claim review of these two L-codes. We will keep you updated as future results become available.

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