Spinal Orthosis 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 L0450, L0452, L0454-L0458, L0460, L0462, L0464, L0466-L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490-L0492, L0621, L0623, L0625-L0643 and L0648-L0651. The final edit effectiveness results from February 2017 through September 2017 are as follows:
The TLSO review involved 63 claims, of which 61 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 97%.
The LSO review involved 962 claims, of which 948 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 100%.
The SO review involved 18 claims, of which 16 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 90%.
The LO review involved 232 claims, of which 231 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 99%.
Top Denial Reasons
- Claim is the same or similar to another claim on file.
- The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- 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 Orthosis 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 Orthosis 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 Orthosis 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 .
Same or similar denials occur when the patient's CMN history indicates a piece of equipment is the same or similar to the equipment being billed.
To determine whether same or similar items have previously been provided, suppliers must obtain all possible information from a patient, which may include the following:
- Patient's correct Health Insurance Claim number;
- Whether the patient has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
- If the patient currently has or had an identical or similar item in the past;
- When the patient received the items and whether or not the items have been returned;
- Where the item will be used; and
- CMN or DIF information, if required.
By using the Suggested Intake Form, it assures this information is obtained. This form is available on our website under the Forms section and it contains beneficiary information, ordering physician information and questions for the beneficiary and the supplier. Suppliers can customize their own intake form to meet their needs as well.
The Noridian Medicare Portal or Interactive Voice Response System can be used to verify that a beneficiary has not had a same or similar item within the previous five years. Follow the steps listed under the manual on the Noridian Medicare Portal to check for same or similar items.
The documentation does not include verification that the equipment was lost, stolen, or irreparably damaged in a specific incident.
The definition of replacement is found in the CMS Benefit Policy Manual (Internet-only manual 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entire identical or nearly identical item when it is lost, stolen or irreparably damaged.
Beneficiary owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).
Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no cases can it be less than 5 years. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement.
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.
Documentation does not support coverage criteria.
- 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 Sep 26, 2017