Billing Instructions - LSO and TLSO - JD DME
Billing Instructions - LSO and TLSO
Joint DME MAC Publication
The DME MACs have claims data showing that spinal orthoses are often replaced at a frequency greater than the allowed 5-year reasonable useful lifetime (RUL). Most commonly replacement is with an orthosis described by a different Healthcare Common Procedure Coding System (HCPCS) code than was originally billed. Suppliers are reminded that unless otherwise specified, an item of durable medical equipment, prosthetics or orthotics has a RUL of five (5) years. If the item is lost, stolen, irreparably damaged or there is a change in medical necessity, replacement may be provided sooner than the 5-year RUL.
To avoid claim denials for RUL, suppliers must note in the narrative field on the claim the reason necessitating the early replacement of the same HCPCS code or substitution of a similar HCPCS coded spinal orthosis for the HCPCS code originally billed. Suppliers must maintain this information in their files and make it available upon request. This applies to the following spinal orthosis codes:
Refer to the Spinal Orthoses LCD (L33790), related Policy Articles (A52500 and A55426) on the DME MAC web sites and the CMS Medicare Coverage Database for additional coverage, coding, and documentation requirements.