Correct Coding and Billing of Halo Procedure - JA DME
Correct Coding and Billing of Halo Procedure
Joint DME MAC and PDAC Publication
Posted March 17, 2022
Based on recent analysis of claims submitted to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for a Halo procedure, the DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor want to remind DMEPOS suppliers about the correct coding and billing for these products. While there are multiple HCPCS codes representing products used with a Halo procedure, suppliers should note that code L0830 (HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS) is on the Master List for 2022 as published in the Federal Register Volume 87 No. 9 on January 13, 2022.
The Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Sections 3.3.B and 220.127.116.11 specify that for Medicare claims, only CMS and the DME MACs have the authority to establish Healthcare Common Procedure Coding System (HCPCS) Level II Coding Guidelines.
Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate HCPCS code for that item. Suppliers are required to correctly code for the item billed. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, Local Coverage Determinations (LCDs), LCD-related Policy Articles, or DME MAC articles.
A halo is a medical device used to stabilize the cervical spine after traumatic injuries to the neck, or after spine surgery. The halo device consists of three major components:
- Torso component (vest, body jacket or Milwaukee type orthosis);
- Connecting rods/ bars attaching the torso component to halo ring;
- Metal ring encircling the patient's head that are anchored to the patient’s cranium by metal pins.
L0810 (HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST) describes the metal ring encircling the head, with pins, connecting rods and bars and rigid jacket vest.
L0820 (HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET) describes the metal ring encircling the head, with pins, connecting rods and bars and plaster body jacket.
L0830 (HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS) describes the metal ring encircling the head, with pins, connecting rods and bars that are attached to a rigid thoracic-lumbar-sacral orthosis (TLSO). The Milwaukee type TLSO extends posteriorly to the sacrococcygeal junction and anteriorly to the symphysis pubis for increased stabilization.
L0859 (ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGS AND PINS, ANY MATERIAL) describes the, connecting rods and components, ring, and pins made of a compatible material for magnetic resonance imaging.
L0861 (ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL) describes replacement of the inner liner/interface of the jacket vest or body jacket that the halo procedure is attached.
Payment for a Halo procedure is included in the payment to a hospital or SNF if:
- The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and
- The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after spinal surgery).
A claim should not be submitted to the DME MAC in this situation.
Payment for a Halo procedure is also included in the payment to a hospital or a Part A covered SNF stay if:
- The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the day of discharge; and
- The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.
A claim must not be submitted to the DME MAC in this situation.
Payment for a Halo procedure delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:
- The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and
- The orthosis is provided to the beneficiary within two days prior to discharge to home; and
- The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.
Correct coding is an essential element for correct claim payment. The PDAC contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm ET, Monday through Friday. You may also visit the PDAC website to chat with a representative, or select the Contact Us button at the top of the PDAC website for email, FAX, or postal mail information.
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Last Updated Thu, 17 Mar 2022 16:29:56 +0000