Billing Off-the-shelf Orthotic Devices L0648, L0650, L1833 part of OIG 2018 Work Plan
According to OIG’s report, since 2014 DME claims for three OTS – Off the shelf orthotic devices have increase by 97 percent and the allowed charges have grown by significantly 116 percent, reaching a whopping $349 million alone in 2016.
On January 16, 2018, the Department of Health and Human Services Office of Inspector General or the OIG have published its most recent update to the agency’s Work Plan about this 3 Orthotic Device with HCPCS codes:
L0648 – Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
** Lumbar Brace
L0650 – Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
** Lumbar Brace
L1833 – Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
** Knee Brace
The Social Security Act states that no payment may be made under Medicare Part B for any expenses incurred for items that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
A Medicare Administrative Contractor (MAC) has identified improper payment rates as high as 79 percent for L0648, 88 percent for L0650, and 91 percent for L1833 within its jurisdiction. A top concern of the MAC is a lack of documentation of medical necessity in patients’ medical records. We will examine factors associated with questionable billing for the three orthotic devices, and describe the billing trends for these devices from 2014 – 2016. Specifically, we will evaluate the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim and will analyze billing trends on a nation-wide scale.
DME Billing Coding Tips
- It is imperative that you read the documentation and identify Medical Necessity
- Make predetermination if the beneficiary had not received the same brace for the last 5 years; Medicare will not cover if the patient had the same brace for the last 5 years
- Obtain Receipt signature and dated by the beneficiary or by its authorized signatory;
- Document the reason (Diagnosis and condition of patient, treatment plan and prognosis
- When submitting claims, make sure you append the proper DME Billing Modifier when required.
HCPCS Code Book
Medicare Part B website page
OIG Workplan 2018 include Questionable Billing for Off-the-Shelf Orthotic Devices CLICK HERE https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000271.asp
Final Rule, published November 14, 2018. https://www.govinfo.gov/content/pkg/FR-2018-11-14/pdf/2018-24238.pdf
Medicare supplier directory www.medicare.gov/supplier, or to locate a supplier, ask a question or file a complaint, call 1-800-MEDICARE (1-800-633-4227).
To locate the correct DMAC for each state, see https://www.cms.gov/medicare-coverage-database/indexes/contacts-durable-medical-equipment-medicare-administrative-contractor-index.aspx
The Medicare Claims Processing Manual, for questions about payment for DMEPOS, including delivery and services charges (Section 60 of the Manual) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf
For questions about assignment (and the lack of a limiting charge on some supplies and on Durable Medical Equipment) see https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment
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