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

The Durable Medical Equipment Medical 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 the patient's medical record to show 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 DMEPOS supplier must have a Standard Written Order (SWO) prior to submitting the claim for the orthosis. The SWO must contain all of the elements as described here: Standard Documentation Requirements for All Claims Submitted to DME MACs.

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

Documentation Requirements

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).

The Spinal Orthoses: TLSO and LSO LCD and Policy Article can be located at the following:

  • 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)

 

Last Updated Tue, 28 Dec 2021 17:37:57 +0000