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Linda Collins Blogger

Severe Back Pain

Posted by Linda Collins | December 21, 2012

Jurisdiction D DME MAC Medical Review Department announced the results of a Widespread Prepayment Probe Review of Spinal Orthoses (HCPCS L0631 and L0637) claims. It revealed a high percentage of claims errors due to lack of sufficient documentation, lack of medical necessity, missing proof of delivery, and erroneous claims billing for Part A. As a result of the high error rate, the DME MAC will continue to closely review TLSO claims.

So what can you do to prevent your claims from failing a MAC review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Here is a summary of key requirements:

Reasonable and Medically Necessary

A lumbar-sacral orthosis is covered when 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.

For Medicare to cover any item, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The diagnosis code must justify the need for the TLSO. Additional clinical notes in the medical record outlining the need for the TLSO can support this diagnosis.

Medical Coverage Documentation

Medicare expects that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

In the case of a spinal orthosis, the beneficiary’s medical record must have sufficient objective documentation to validate beneficiary use of a LSO as reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member.

Proof of Delivery

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

Billing for Spinal Orthosis while patient in hospital or SNF

A spinal orthosis delivered to a beneficiary while inpatient at a hospital or SNF will not be paid separately and is included in the facility payment.
According to DME MAC, a spinal orthosis claim may considered for separate payment when a spinal orthosis is delivered to patient in hospital or Part A covered SNF if:

  1. The orthosis is medically necessary for a patient after discharge from a hospital or Part A covered SNF stay; and
  2. The orthosis is provided to the patient within two days prior to discharge home; and
  3. The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the patient to take home.

The full report is available at:
Following a few clearly defined requirements will mean that your claims are more likely to pass reviews and audits, which means quicker payment for you.

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