Medicare Documentation Requirements:
Spinal Orthosis Medicare Documentation Requirements-L0650 HCPCS
By Angela Breslin, BSN, R.N
Simply stated, Medicare documentation is the key to a quality driven, results achieving, compliant and successful business. This applies to DME providers, physicians, home health agencies, long term care facilities, or any Medicare approved supplier. Most Medicare claims that are denied are denied due to issues related to Medicare documentation errors.
Medicare states that the Medicare documentation, “should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not be medically necessary.”
Additionally, at a high level, Medicare documentation should meet all of the following expectations:
- All Medicare documentation should be complete, legible, signed and dated
- Medicare documentation is the recording of pertinent facts of and observations about an individual’s health history, including past and present illness, test results, treatment and outcomes.
- The Medicare documentation of each patient encounter should include: the date, the reason for the encounter, appropriate history and physical exam, review of lab results, x-ray results, other ancillary services (where appropriate) assessment, and plan of treatment
- If your billing codes are time based, then the Medicare documentation must clearly and accurately notate how much time was spent with the Medicare beneficiary.
- If your billing for E/M services, you need to be sure that your Medicare documentation includes History of Present illness (HPI), Review of Symptoms (ROS), and Past Medical, Family, and Social History (PFSH)
- Your Medicare documentation should clearly and accurately include the proper ICD-10’s that are required for treatment, testing, and payment
- Your modifiers, if appropriate, should reflect what story the Medicare documentation tells
Medical Records Documentation Requirements: Spinal Orthoses L0650 HCPCS
1. Dispensing Order, if applicable- Verbal Order
2. Doctors Written order- DWO
3. Medical necessity requirements that MUST be documented in the medical records:
a. Does the spinal orthosis support a weak or deformed body member?
b. Does the spinal orthosis eliminate motion in a diseased or injured part of the body?
4. Medicare Coverage criteria for spinal orthosis that must be met: Atleast one must be documented in the medical records:
a. To reduce pain by restricting mobility of the trunk; OR
b. To facilitate healing following an injury to the spine or related soft tissues; OR
c. To facilitate healing following a surgical procedure on the spine or related soft tissue; OR
d. To otherwise support weak spinal muscles and/or a deformed spine
5. Proof of Delivery
Medicare providers must take note that the L0650 Spinal Orthosis is on all regulatory workplans making this HCPCS one of the most regulated in the industry. With RAC’s UPIC’s, and the OIG focused on cleaning up the medical necessity piece, you must be compliant with all Medicare documentation and medical necessity guidelines or it will cost you dearly in terms of medicare denials, medicare recoupments, medicare payment suspensions, and the type of attention most strive to avoid.
In fact, Noridian recently published the denial rates and denial reasons for recent TPE audit results; and the denial rate was 60% of all files audited during a Medicare Spinal Orthoses TPE audit.
Top reasons for Spinal Orthoses TPE Audit denials are:
1. Claim is same or similar to another claim on file
a. Best practice is the run a same/similar check prior to billing
2. Medical documentation requested for the TPE audit (ADR Letter) was not received
3. Medical documentation does not include verification that the spinal orthosis was last, stolen or irreparably damaged in a specific incident
4. No medical documentation for spinal orthosis was received
Finding and teaming with a Medicare LCD and Documentation expert is critical if you find yourself under the spotlight from a Medicare Contractor, Auditor, or investigator. Boost Advisory Group is ready and competent to advise, educate, and respond to any and all Medicare audits, appeals, and recoupments. Boost Advisory Group has helped many Medicare providers successfully win appeals and defend audits, in fact, Boost Advisory Group can help you audit proof your business and we provide a 100% satisfaction guarantee.
About the author:
Angela M. Breslin is a Registered Nurse (BSN, RN) with some 20 years of clinical experience in a hospital setting. Angela is an expert in Medicare, Medicare, Medicaid, third party payor audits