Due to an increase in claims in the third and fourth quarters of 2012, the Medical Review Department of National Government Services (NGS), the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), said it will be initiating a widespread prepayment probe of thoracic-lumbar-sacral orthoses (TLSOs) and lumbar-sacral orthoses (LSOs). Suppliers will receive an Additional Documentation Request (ADR) letter requesting the following information:
- A physician’s detailed written order with Healthcare Common Procedure Coding System (HCPCS) codes and a detailed description of all the items ordered.
- A dispensing order if the detailed written order is signed and dated by the treating physician after the date of service on the claim.
- Any medical records from the place of services rendered, physician history, and progress notes, diagnoses/conditions, physicals, diagnostic testing, lab tests, and any other pertinent information.
- Provide documentation to allow the nurse reviewer to understand the medical necessity of the orthoses chosen.
- Provide documentation to substantiate the choice of custom made over prefabricated if applicable.
- Make sure all medical records are signed and dated by the physician.
- Include certified prosthetist/orthotist documentation regarding evaluation and fitting if applicable, signed and dated legibly.
- Non-physician clinical assessments and progress notes from nurses, physical therapists, occupational therapists, and ancillary services.
- Make sure these are signed and dated legibly.
- Copies of the supplier’s records for dates of direct patient contact related to the evaluation, fitting, and delivery of the orthosis.
- Manufacturer’s name and model name and number of the items provided. Include information about the fabrication of any item submitted if it is considered custom.
- Any Advance Beneficiary Notice (ABN) issued to the beneficiary for each date of service and each specific service an ABN was issued.
NGS also asks that when submitting additional documentation, suppliers should ensure that all medical necessity documentation is current for the date of service and that responses be submitted within the timeframe indicated in the letter.
NGS provided the following links to educational material so suppliers can be in compliance with documentation requirements:
- Local coverage determination (LCD) L-27017.
- Article 47059.
- The LCDs and related policy articles for items that are billed by suppliers can be found under Medical Policy Center (LCDs).
- Policy Education provides additional information for medical policies.
- Chapter 8 of the Jurisdiction B DME MAC Supplier Manual documentation requirements.
NGS reminded suppliers that failure to respond to requests for additional documentation is in violation of supplier standard 28.