Spinal Orthoses (HCPCS L0631, L0637) Final Edit Effectiveness Results of Service Specific Prepayment Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code L0631 and L0637. The final edit effectiveness results from March 2017 through August 2017 are as follows:
The L0631 review involved 159 claims, of which 156 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 98%.
The L0637 review involved 169 claims, of which 162 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 96%.
Top Denial Reasons
- Documentation does not support custom fit criteria.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not support PDAC approval.
- Documentation does not support coverage criteria.
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Spinal Orthoses Local Coverage Determination (LCD) L33790, Policy Article A52500 [PDF] and Standard Documentation Requirements Article A55426 (effective 1/1/2017).
Suppliers can also review specific policy resources for Spinal Orthoses on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during Web-based workshops.
Suppliers can also review a specific policy Documentation Checklist for Spinal Orthoses on the Noridian website.
Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.
Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 .
Custom fitted orthotics are:
- Devices that are prefabricated
- They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
- Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
- This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.
Substantial modification is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.
Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.
Claims for custom fitted orthoses (L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0626, L0627, L0630, L0631, L0633, L0635, L0637 and L0639) will be denied as incorrect coding, with a statutory denial, when documentation shows that only minimal self-adjustment was required at the time of fitting (see Policy Specific Documentation Requirements section in the Local Coverage Determination).
Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).
Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian's website.
Effective for claims with dates of service on or after July 1, 2010, spinal orthoses which have not received coding verification review from the Pricing, Data Analysis, and Coding (PDAC) contractor will be denied as statutorily noncovered, no benefit category.
Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes, L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630, L0631, L0633, L0635, L0637, and L0639 for prefabricated orthoses (both OTS and custom fitted) are those that are specified in the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor web site.
Suppliers should contact the PDAC Contractor for guidance on the correct coding of these items.
A spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.
A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. (PIM 5.2.3)
Last Updated Jan 17, 2018