Clinicians! Are You Ordering a Spinal Orthosis for Your Patient? - JD DME

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are providing helpful guidance to assist the supplier in providing a spinal orthosis to your patient. Medicare must be able to verify that there is supporting medical record documentation for the provision of a spinal orthosis for your patient.

Medicare coverage requires that the patient's medical record shows the orthosis is medically necessary and that there is a valid and complete order for the orthosis.

Coverage Criteria Documentation Requirements

A spinal orthosis (L0450 - L0651) is covered when it is ordered for one of the following indications:

1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. 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.

The supplier must have a Standard Written Order (SWO) prior to submitting a claim to Medicare or a Written Order Prior to Delivery (WOPD) and face-to-face encounter for items on the required-face-face-encounter-and-written-order-prior-delivery-list.pdf (cms.gov)  The SWO must contain the elements listed below. Assist your patient by providing the order and documentation to substantiate need in a timely manner. In addition to the "reasonable and necessary" criteria outlined in the LCD, there are further payment rules related to documentation requirements. For details related to those documentation requirements, review the Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).

Standard Written Order (SWO) Elements

An order must contain the following elements to be considered a valid SWO:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., spinal orthoses), a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
  • For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

Documentation Requirements

Medicare requires that all HCPCS codes that appear on the Required Prior Authorization List must be submitted for prior authorization before delivery and claim submission.

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the beneficiary's medical records will reflect the need for the care provided. All orders and medical records must meet CMS Signature Requirements.

For additional information on the coverage and limitations of spinal orthoses, review the Spinal Orthoses: TLSO and LSO Local Coverage Determination (LCD) (L33790) and the LCD-related Policy Article (A52500).

Help your patient by providing this information in a timely manner.

Additional information is located on the DME MAC contractor websites:

• Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia)
• Jurisdiction B (IL, IN, KY, MI, MN, OH, WI)
• Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
• Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)

Revised January 11, 2023