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Spinal Orthoses: TLSO and LSO (HCPCS L0648, L0650) Notification of Service Specific Prepayment Targeted Review

Noridian Jurisdiction A, DME MAC, Medical Review will be initiating a service specific prepayment targeted review of claims for each of the following HCPCS code(s)

  • L0648: LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF
  • L0650: LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF

Service specific targeted reviews are initiated to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis. This review is being initiated based on a high Comprehensive Error Rate Testing (CERT) error rate.

In order to evaluate compliance with Medicare coverage and coding rules, all suppliers billing Jurisdiction A for HCPCS codes listed above are subject to this review. Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria.

  • Treating physician's dispensing and written order
  • Patient's medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided are reasonable and necessary
  • Justification to support the custom fitted or off the shelf orthosis code billed (if applicable)
  • Reason for replacement (if applicable)
  • Proof of delivery
  • The Advance Beneficiary Notice of Noncoverage (ABN) (if applicable)
  • Any other supporting documentation

Failure to supply the above requested information within 45 days of the date of the letter will result in the claim being denied. Please fax or mail the requested documentation and a copy of the ADR letter. The ADR letter provided will also provide instruction for submitting documentation.

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Spinal Orthoses: TLSO and LSO Local Coverage Determination (LCD) L33790 and Policy Article A52500 on the Active LCDs webpage.

Additional information, educational opportunities and training tools related to this product category are available in Education & Outreach.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 This link will take you to an external website.

Last Updated Jun 21, 2016