Table C. Prefabricated Orthotic Codes Split into Two Codes- Effecfabricated Off-the-Shelf back braces that required only “minimal self-adjustment by the patient.”
tive January 1, 2014 Fee from Existing Code
Crosswalk to New Off-theShelf and Revised Custom Fitted Orthotic Codes
L0454
L0455 and L0454
L0456
L0457 and L0456
L0466
L0467 and L0466
Now, mind you, if you look up the allowable for both L0631 and L0648 (in my locale, at least), they are the same! Therefore, using an incorrect code did not cost the federal government financially. However, the practice referred to in this article filed a Redetermination and was not successful in getting this point of confusion across, and as a result, Health Integrity determined the appeal unfavorable.
L0468
L0469 and L0468
L0626
L0641 and L0626
L0627
L0642 and L0627
L0630
L0643 and L0630
L0631
L0648 and L0631
L0633
L0649 and L0633
L0637
L0650 and L0637
There were other items, however, that impacted the Redetermination decision. After you have a chance to look at the table below, I will point out very important details that you must have in your documentation to successfully withstand an audit.
L0639
L0651 and L0639
L1810
L1812 and L1810
L1832
L1833 and L1832
L1847
L1848 and L1847
L3807
L3809 and L3807
L3915
L3916 and L3915
L3917
L3918 and L3917
L3923
L3924 and L3923
L3929
L3930 and L3929
L4360
L4361 and L4360
L4386
L4387 and L4386
L4396
L4397 and L4396
The back braces billed after January 1, 2014, however, were taken from inventory on hand at the practice and the labels still had the L0631 code on them. This fact contributed to the incorrect assignment of code L0631 after that date for a code that now required fitting and adjustment to the patient.
See table C right What is required to document in the Medical Record for these items in order to prevent denial due to Medical Necessity? Failure to follow LCD guidelines can indicate the reason for denial and recoupment. The tips below may help to ensure that you prevent an unfavorable audit result for your practice/clinic. 1. Read and understand all specific LCD requirements. When they mention certain required items, they mean it. The LCD for each MAC Carrier can be found on their respective websites and on the CMS website. Here is an example of what it looks like when accessed on the CGS DME Carrier’s website at: https://www.cms.gov/medicare-coverage-database/details/ lcd-details.aspx?LCDId=33790&ContrID=140. Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790) LCD #L33790 has an original effective date for services on or after 10/01/2015 and a revision effective date for services performed on or after 07/01/2016.
2. Follow the coverage guidelines for establishing medical necessity and make sure that the same wording is used in the documentation and required forms when appropriate for each specific patient. Sharing this information with your providers can help them understand what needs to be included in the medical record for sufficient documentation. Each LCD begins with the statement concerning General Coverage Guidance that provides the basis for proper payment by the Medicare Administrative Contractor (MAC) for your region. It states: For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of malformed body member, and
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