DME Compliance Alert: Back Braces Under Specific Review by Medicare

By: Susan St. John

DME Compliance Alert: Department of Health and Human Services, Office of Inspector General, updated its work plan in January 2018 to include heightened scrutiny of off-the-shelf orthotic devices, specifically back braces for HCPCS Cods L0648, L0650 and L1833 due to one MAC identifying improper payment rates as high as 79 to 91 percent. Of specific concern is the lack of documentation of medical necessity, including Medicare beneficiaries being prescribed back braces without an encounter with the referring physician within 12 months prior to an orthotic claim being filed. The OIG plans to analyze billing trends nationwide, and expects to issue a report sometime in 2019.

Further, as a result of Comprehensive Error Rate Testing (CERT) analysis and results, DME MAC, Noridian, will be initiating a specific prepayment probe review of claims for HCPCs codes L0648 and L0650, to determine potential problems across multiple suppliers. All DME suppliers in Jurisdiction D will be subject to Noridian’s review. If a claim is pulled for review, the Supplier will receive an Additional Documentation Request (ADR) letter to support that the billed for the orthotic device is reasonable and necessary for the patient’s condition. The ADR letter will ask for the following:

1. Treating physician’s dispensing order or written order for the back brace;
2. Patient’s medical records, including, physician medical records; hospital records; nursing home records; home care nursing notes and/or physical/occupational therapy notes;
3. Justification to support the custom fitted or off-the-shelf orthosis code billed;
4. Proof of delivery;
5. Advance Beneficiary Notice (if applicable); and
6. Any other supporting documentation.

If a DME provider fails to provide the requested information within 45 days from the date of the letter, Noridian will deny the claim.

As a best practice, prior to billing Medicare or any third-party payor for a back brace or any orthotic device, the supplier needs to ensure that it has proper documentation to justify billing of the orthotic device. It may be necessary to obtain specific authorization from patients to obtain a primary care practitioner’s or a specialist’s notes or patient records pertaining to the patient’s condition and necessity of the orthotic device prescribed. If a DME provider is unsure or whether its following best practices for complying with billing Medicare or other third-party payors, it should seek advice of competent health care counsel to help it assess how to improve its processes.