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By Kim Turner, RN, Clinical Consultant

Medicare coverage requires that the LSO is rigid or semi-rigid to support a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.

There are three types of LSOs: off-the-shelf (OTS), custom fitted, and custom fabricated. An LSO is covered by Medicare when it’s ordered for one of the following reasons:

1. To reduce pain by restricting mobility of the trunk
2. To help healing following an injury to the spine or related soft tissues
3. To help healing following a surgical procedure on the spine or related soft tissue
4. To otherwise support weak spinal muscles or a deformed spine or both

When providing an LSO, a supplier must:

• Provide the product that is specified by the prescribing practitioner
• Be sure that the prescribing practitioner’s medical record justifies the need for the type of product (that is, prefabricated versus custom fabricated
• Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
• Have detailed documentation in supplier’s records that justifies the HCPCS code selected

Selecting the proper HCPCS for an LSO/spinal orthosis is dependent upon whether there’s a need for “minimal self-adjustment” during the final fitting at the time of delivery.

• For prefabricated orthoses, there’s no physical difference between orthoses coded as custom fitted versus those coded as OTS. The difference is in the fitting at time of delivery. There must be detailed documentation in the medical record to support the adjustments or modifications made at the time of delivery.
• Items requiring more than minimal self-adjustment by a qualified practitioner are coded as custom fitted and documentation must be sufficiently detailed to include, but not limited to a detailed description of the modifications necessary at the time of fitting.

Reminder, if a custom prefabricated fit code is billed when minimal self-adjustment was provided at final delivery, or if an OTS code is billed when more than minimal self-adjustments were made at final delivery, Medicare will deny the claims.

Insufficient Documentation results in the following Common CERT errors:

• Documentation for the fitting of the orthosis at time of delivery (that is, minimal or more than minimal self-adjustment)
• A valid provider’s order that includes all elements required by regulation, Medicare program manuals, and Medicare Administrative Contractor (MAC) specific guidelines
• Proof of delivery is missing or inadequate per regulations and Medicare program manuals

Want to ensure your documentation meets Medicare requirements? Contact us today for more information on how our clinical team can help.