Post

By Kay Koch, OTR/L, ATP- Rehab Clinical and Education Consultant Last year, the Jurisdiction A DME MAC Medical Review Department conducted a service specific review of Spinal Orthoses , specifically on HCPCS codes, L0648 and L0650 . For code L0648, 413 claims reviewed, of which 285 were denied. This reflects an overall claim potential improper payment rate of 70%. For code L0650, 693 claims reviewed, of which 399 were denied. This reflects an overall claim potential improper payment rate of 58%. The top 4 denial reasons provided were:

• Documentation does not support coverage criteria
• Medical record documentation was not received
• Medical record documentation was not authenticated ( handwritten or electronic) by the author
• Documentation was not received in response to the ADR ( Additional Documentation Request) letter

It is expected that the beneficiary’s medical records will document the need for the care or item provided. These medical records include the physician’s office records, hospital records, home health agency records, records from other healthcare professionals and any test reports. The records should contain sufficient documentation of the patient’s medical condition to substantiate the necessity which should include the patient’s diagnosis, condition or clinical course (worsening or improving), prognosis and extent of functional limitation or other therapeutic interventions tried and the results pertaining to the item requested. Remember neither a physician’s order nor a CMN or a supplier created statement or physician’s attestation by itself is considered sufficient documentation of medical necessity. A prescription is not considered as part of the medical record. Medical information intended to demonstrate coverage criteria may be included on the prescription but must be corroborated by the information contained in the medical record. Avoiding the denial Review the LCD for coverage criteria and use a documentation checklist (created by the DME MAC) to ensure coverage criteria is met. If the coverage criteria is not met, the item will be denied as not medically necessary. Medicare will cover a spinal orthosis ( HCPCS codes L0450-L0651) for one of the following indications:

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

As a DME Supplier, you may need to educate your physicians on the documentation required by Medicare to meet the coverage criteria for Spinal Orthoses. Orthoses, including spinal orthoses, are currently under heavy scrutiny by the UPICs/ZPICs and DME MACs. Further, the Office of Inspector General (OIG) has included Questionable Billing for Off-the-Shelf Orthotic Devices (including HCPCS L0648, L0650) to their Work Plan for this year. Make sure you are compliant with CMS billing and coverage guidelines and protect your business from additional audit scrutiny. Contact us to learn how we can help!