Spinal Orthoses

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What’s Changed?

We updated the improper payment rate and denial reasons for the 2024 reporting period.

Affected Providers

Treating practitioners and DME suppliers who bill for spinal orthoses.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Spinal Orthoses: TLSO and LSO (L33790) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for lumbar-sacral orthosis (LSO) is 54.4%, with a projected improper payment amount of $47.8 million.

We outline other policy requirements in LCD L33790 and Article: Spinal Orthoses: TLSO and LSO (A52500).

Denial Reasons

Insufficient documentation accounted for 64.4% of improper payment rates for LSO during the 2024 reporting period, while no documentation (20.1%), medical necessity (0.3%), and other errors (15.1%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Coverage Criteria

The Medicare braces benefit covers LSO and thoracic-lumbar-sacral orthoses (TLSO). For coverage under this benefit, the orthosis must be a rigid or semi-rigid device, used to support a weak or deformed body member or to restrict or end motion in a diseased or injured body part. We may specifically cover a spinal orthosis to treat 1 of these:

Reduce pain by restricting trunk mobility
Ease healing after injury to the spine or related soft tissue
Ease healing after surgical procedure on the spine or related soft tissue
Otherwise support weak spinal muscles or a deformed spine

Billing & Coding Criteria

We consider both off-the-shelf (OTS) and custom-fit items as prefabricated braces for Medicare coding purposes. Correct coding of a spinal orthosis depends on whether the patient needs minimal self-adjustment during final fitting at delivery.

The DME Medicare Administrative Contractor (MAC) covers payment for a spinal orthosis, delivered to a patient in a hospital or Medicare Part A-covered skilled nursing facility (SNF) stay, if:

The orthosis is medically necessary for the patient after discharge from the hospital or Part A-covered SNF stay
The patient gets the orthosis within the 2 days before discharge to home
Inpatient treatment or rehabilitation doesn’t require the orthosis, which is left in the room for the patient to take home

We include payment for spinal orthoses in the payment to a hospital or SNF for a Part A-covered stay in certain situations. Don’t submit claims to your DME MAC for spinal orthoses payment if any of these apply:

The patient gets the orthosis before the inpatient hospital admission and Part A-covered SNF stay, or during their inpatient hospital stay or Part A-covered SNF stay before the day of discharge
Medical necessity for the orthosis starts during the hospital or SNF stay (for example, after spinal surgery)
The patient uses the item for medically necessary inpatient treatment or rehabilitation

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS including proof of delivery..

NOTE:
We require a face-to-face encounter and written order prior to delivery for some LSOs (HCPCS codes L0631, L0635 – L0640, L0648, L0650, and L0651). We require prior authorization for L0631, L0637, L0639, L0648, and L0650. See the Prior Authorization Process for Certain DMEPOS Items Operational Guide for a full description of the prior authorization requirements, and see the Required Face-to-Face Encounter and Written Order Prior to Delivery List.

NOTE:

We require a face-to-face encounter and written order prior to delivery for some LSOs (HCPCS codes L0631, L0635 – L0640, L0648, L0650, and L0651). We require prior authorization for L0631, L0637, L0639, L0648, and L0650. See the Prior Authorization Process for Certain DMEPOS Items Operational Guide for a full description of the prior authorization requirements, and see the Required Face-to-Face Encounter and Written Order Prior to Delivery List.

Example of Improper Payments Due to Insufficient Documentation for Spinal Orthoses

A supplier bills the claim for HCPCS code L0631 (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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) and submits the following documentation per the review contractor’s request:

Standard written order with correct HCPCS coding
Treating practitioner’s medical record documenting spinal orthoses

What Documentation Was Missing?

The supplier didn’t send proof of delivery to the review contractor.

What Happens Next?

The review contractor completes the claim as a no documentation error, and the MAC recoups payment.

Recommendation

To avoid billing errors and improper payments, suppliers must include proof of delivery in the treating practitioner’s medical record for DMEPOS.

Additional Resources

Disclaimers

View Disclaimers