Noridian Administrative Services (NAS), the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced that it is initiating service-specific prepayment probe reviews of claims for spinal and knee orthoses. Service-specific prepayment probes are used to determine the extent of potential problem areas across multiple suppliers. The review is based on the results of Comprehensive Error Rate Testing (CERT) analysis and previous review results. All suppliers billing Jurisdiction D for the following Healthcare Common Procedure Coding System (HCPCS) codes are subject to this review.
- L-0648: 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.
- L-0650: Lumbar-sacral orthosis, sagittal 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 the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf.
- L-1832: Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
- L-1833: Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf.
- L-1843: Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
Suppliers of the selected claims will receive an Additional Documentation Request (ADR) letter asking for the following specific information to determine if the item billed complies with the existing reasonable and necessary criteria:
- Treating physician’s dispensing (if the item is dispensed on a dispensing order) and written order.
- Patient’s medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that may support the item(s) provided are reasonable and necessary.
- The justification for the code selected for a custom-fitted versus an off-the-shelf orthosis (if applicable).
- Proof of delivery.
- The Advanced Beneficiary Notice (if applicable).
- Any other supporting documentation.
