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Linda Collins Blogger

The Heat is BACK

Posted by Linda Collins | May 28, 2013

MAC Region D just released the results of its widespread pre-payment review of codes L0631 and L0637 (spinal orthoses codes) for the first quarter of 2013. The audit revealed a high percentage of claims errors due of lack of medical necessity documentation, missing proof of delivery, missing Detailed Written Orders, and the failure of suppliers to respond to additional documentation requests. These results are similar to previous findings by Region D (see, Severe Back Pain post, December 21, 2012) and Region A (see, Back-to-Back post, March 25, 2013).

Region D denied the majority of the claims for not meeting medical necessity requirements. In other words, the documentation provided did not support the need for the spinal orthosis. The second most common reason for claims denial was the failure to respond to Region D’s requests for additional documentation.

Finally, Region D denied a significant percentage of claims for inadequate/missing Proof of Delivery (POD) and Detailed Written Order (DWO).

What does this mean to me?

First, according to the LCD, you can only provide spinal orthoses if the device will

  • reuce pain by restricting mobility of the trunk; or
  • facilitate healing following an injury to the spine or related soft tissues; or
  • facilitate healing following a surgical procedure on the spine or related soft tissue; or
  • otherwise support weak spinal muscles and/or a deformed spine.

You must record these conditions in the patient’s medical record and confirm that the doctor does the same.Documents created by you and dated/initialed by the doctor do not satisfy this requirement! Rather, the doctor’s own notes must contain the required information

Second, as a supplier, you must provide additional documentation to Medicare or a Medicare contractor upon request. After submission but before payment, an auditor may ask for copies of your supporting documentation. Failure to provide it will result in an automatic claim denial and may put you at risk for additional audits. Respond to all requests for documentation, even if you believe your notes are insufficient.

Lastly, comply with the LCD’s requirements:

If you dispense an item based on a verbal order, you must have the following documentation:

  • Description of the item
  • Name of the beneficiary
  • Name of the physician
  • Start date of the order

Do not submit claims before obtaining a valid written order that contains:

  • Beneficiary's nameDetailed description of the item(s) to be dispensed (The detailed description in the written order may be either a narrative description or a brand name/model number.)
  • Treating physician's signature (Signature and date stamps are not allowed.)
  • Date the treating physician signed the order
  • Start date of the order - if the start date is different than the signature date

Beneficiary authorization

Proof of delivery

Product information demonstrating that the TLSO provides control of motion in one or more planes or provides intracavitary pressure

Documentation in the beneficiary’s medical records that supports that the TLSO was ordered for one of the following indications:

  • To reduce pain by restricting mobility of the trunk; or
  • To facilitate healing following an injury to the spine or related soft tissues; or
  • To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  • To otherwise support weak spinal muscles and/or a deformed spine.

Taking the time to organize documents before claims submission will help you respond to prepayment audits in a timely and efficient way.

 

 

We offer additional help under the “Reimbursement Resource” link on the left side of this page. Please note that we have created a Spinal Orthoses Claims Checklist to assist you in gathering the necessary documents prior to claims submission for these devices.​

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