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Performant Recovery posted one new automated issue to their approved issues log this month.

Spinal Orthosis (TLSO/LSO) within the Reasonable Useful Lifetime

On January 1, 2019, Performant Recovery, the National DMEPOS RAC, added Spinal Orthosis (TLSO/LSO) within the Reasonable Useful Lifetime to their approved issues list. According to their website, Performant Recovery will perform automated reviews on claims for more than one spinal orthosis within the reasonable useful lifetime and within 180 days. Spinal Orthosis within the Reasonable Useful Lifetime [RUL]), for the same anatomical site, will be denied.

Code(s) included in the audit: L0627, L0631, L0637, L0642, L0648, L0650

Dates of service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date

Applicable policy references:

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions
7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and edeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
8. 42 CFR §405.986- Good Cause for Reopening; 42 CFR §414.210- General Payment Rules; 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
9. 42 CFR §424.57(c)- Application Certification Standards
10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
12. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements
13. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders
14. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis
15. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record
16. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation
17. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity
18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program.

Contact us for more information!

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.