Practitioners, Are You Ordering Lower Limb Orthoses for Your Patients?

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are providing helpful guidance to assist suppliers in providing a lower limb orthosis to your patient. Medicare must be able to verify that there is medical record documentation to support the orthosis you are prescribing.

Medicare coverage requires the patient's medical record to show the orthosis is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

For coverage criteria related to lower limb orthoses, review Local Coverage Determinations (LCD) and Policy Articles for Ankle-Foot Orthoses/Knee-Ankle-Foot Orthoses (L33686 and A52457) and Knee Orthoses (L33318 and A52465).

The supplier must have a Standard Written Order (SWO) prior to submitting a claim to Medicare. 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 Local Coverage Article (LCA) 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., wheelchair or hospital bed), 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

LCDs and Policy Articles for lower limb orthoses can be 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)

 

            Last Updated Fri, 12 Feb 2021 17:42:49 +0000