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Linda Collins Blogger

Spinal Orthoses Audit Results

Posted by Linda Collins | January 26, 2015

National Government Services, Jurisdiction B, released results of a prepayment audit on Spinal Orthoses, HCPCS L0450-L0640. The 2014 third quarter audit resulted in a 96.2% claim error rate. The outcome shows the top denial reasons as:

  • A detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary was not submitted.
  • No Pricing, Data Analysis and Coding (PDAC) contractor verification.
  • No Proof of Delivery from the supplier.
  • No medical records were submitted

What does this mean for you?

Custom fit orthoses are identified as those products requiring substantial modification at time of fitting. The modifications must be documented, in detail, in the patient’s medical records. Substantial modifications are those beyond what the beneficiary could perform at home, such as a simple adjustment or tightening a strap.

An example of appropriate documentation might be “Customized back panel by removing panel, treating with heat gun, trimmed and reassembled to accommodate lordosis.”

As a reminder, Medicare does not allow templates or checklists as documentation. See Templates and Checklists as Documentation

Spinal Orthoses (TLSO and LSO) require coding verification review by the Pricing, Data Analysis and Coding (PDAC) contractor. Claims with these product codes will be denied if they are not listed on PDAC. It is not necessary to obtain the actual coding verification letter, but you should check the product listing at

A  valid Proof of Delivery (POD), which includes a beneficiary’s name, delivery address, detailed listing of products delivered, and patient’s signature, is required for all orthoses. For additional information, see Proof of Delivery Requirements.

When a claim is selected for pre-payment review, the contractor sends an Additional Documentation Request (ADR) letter to the supplier. The supplier has 45 days from the date of the letter to respond by providing the appropriate documentation (e.g. patient medical records, POD.) Failure to respond results in claims denial. Respond to all requests within the specified timeframe.

Document, verify PDAC, obtain signatures and respond to submissions. Incorporate these practices into your business to avoid prepayment claims denials.

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