Spinal Orthosis (HCPCS L0457, L0631 & L0650) Notification of Service Specific Post-Payment Review - JD DME
Spinal Orthosis (HCPCS L0457, L0631 & L0650) Notification of Service Specific Post-Payment Review
Noridian Jurisdiction D, DME MAC, Medical Review is initiating service specific post-payment medical record review of claims for the following HCPCS codes:
- L0457: TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL AND SOFT ANTERIOR APRON, EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, OFF-THE-SHELF
- L0631: 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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE
- 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 reviews are initiated to prevent improper payments for services which present possible sustained or high-level payment errors. This review is being initiated based on data analysis identifying probable vulnerabilities.
In order to evaluate compliance with Medicare coverage and coding rules, all suppliers having billed Jurisdiction D for the HCPCS codes listed above are subject to review. Suppliers will receive a coversheet identifying the selected claim and a notification letter with instructions for submitting documentation supporting the following information:
- Treating practitioner's written order
- Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
- Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), Policy Article, and/or Standard Documentation Requirement Article (A55426) requirements
- Any other supporting documentation
Failure to supply the above requested information within 45 days of the letter date will result in initiation of claim adjustments or overpayment recoupments for the undocumented items. The following methods may be used for documentation submission:
- Noridian Medicare Portal - https://www.noridianmedicareportal.com
- Electronic Submission of Medical Documentation (esMD);
- For more information about esMD, see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD
- CD/DVD using the appropriate mailing address
In addition to federal laws, regulations, and CMS manuals, the following references will be used in the medical review of the claims and can be accessed on the Noridian website.
- Local Coverage Determination (LCD) L33790
- Policy Article A52500
- Standard Documentation Requirements Article A55426
Additional information, educational opportunities, and training tools related to this product category are available on the Education & Outreach webpage.
Information about post-payment reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.
Last Updated Mon, 01 Feb 2021 14:27:21 +0000