Spinal Orthosis (HCPCS L0631 & L0650) Final Edit Effectiveness Results of Service Specific Post-Payment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a post-payment service specific review of HCPCS codes L0631 and L0650. The final edit effectiveness results from August 2021 through November 2021 are as follows.

Based on dollars, the overall claim potential improper payment rate is 86% for HCPCS L0631.

Based on dollars, the overall claim potential improper payment rate is 62% for HCPCS L0650.

Top Denial Reasons

  • Documentation was not received in response to the Post-Payment Notification Letter.
  • Documentation does not support coverage criteria.
  • Medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4.
  • Medical record documentation contains a practitioner’s signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Orthotics webpage to access coverage documents.

  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Policy Article
  • Documentation letters, forms, and checklists
  • Review tips, tools, and resources
  • Related articles
  • Educational events and tutorials, if applicable

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 for more information on medical record reviews.

 

Last Updated Fri, 14 Jan 2022 13:44:05 +0000