Skip navigation
9

Linda Collins Blogger

Spinal Orthoses - Coverage Requirements

Posted by Linda Collins | March 29, 2016

Spinal Orthoses claims continue to be a focus of audits. A review of the documentation and billing requirements will help you prepare to defend the claim in case of an audit.

Spinal Orthoses: TLSO and LSO (L0450 - L0651)

According to this LCD, spinal orthoses are covered for patients when the brace is prescribed to:

  1. Reduce pain by restricting mobility of the trunk: OR
  2. Facilitate healing following an injury to the spine or related tissue; OR
  3. Otherwise support weak and/or deformed spinal muscles.

What does this mean for you?

Check your documentation and billing practices to assure you are meeting all the requirements to bill a spinal orthoses.

  • Spinal Orthoses billed with HPCPCS L0450, L0454, L0621, L0625 and L0628 must be billed with the CG modifier if the brace is made of canvas, cotton, nylon or other non elastic material.
  • Your documentation must show the brace is needed for one of the reasons listed above.
  • The prescribing physician's chart notes must also document at least one of the three criteria have been met.
  • Neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier.
  • Custom-fit codes must include documentation of the substantial modifications made to the brace. If there are not substantial modifications done then the Off the Shelf Code should be billed.
  • In order to bill TLSO and LSO products to Medicare, there must be a written coding verification by the Pricing, Data Analysis, and Coding (PDAC) contractor (see Products Requiring PDAC Coding Verification.) You do not need a copy of the actual PDAC Coding Verification letter from the manufacturer, but you do need to verify the listing on  http://www.dmepdac.com/
  • If a spinal orthosis is delivered to a beneficiary in a hospital or SNF for use during the inpatient stay (e.g. for use after surgery and/or as part of the inpatient rehabilitation protocol), Medicare's payment to the facility covers the cost of the brace. The only exception to this rule is when the spinal orthosis is delivered to the beneficiary in the hospital within 48 hours of discharge and is intended for use at home.

Additional information about Spinal Orthosis billing may be found in the Össur Reimbursement Guide for Spinal Bracing

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com