Spinal Orthoses Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L0625, L0626, L0627, L0630, L0631, L0637, L0641, L0642, L0643, L0648 and L0650. The quarterly edit effectiveness results from January 2019 through March 2019 are as follows:
Based on dollars, the overall claim potential improper payment rate is 60%.
Top Denial Reasons
- Claim is the same or similar to another claim on file
- Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident
- 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.
Suppliers can also review specific policy resources for Spinal Orthoses. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, and FAQs.
Suppliers can also review a specific policy Documentation Checklist for Spinal Orthoses.
Noridian provides education via supplier webinars, 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
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.
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.
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 Jun 27, 2019