Documentation and Billing Practices

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Feb 1st, 2016 - Reviewed/Updated Aug 7th

Prescribed to:

1. Reduce pain by restricting mobility of the trunk: OR
2. Facilitate healing following an injury to the spine or related tissue; OR
3. Otherwise support weak and/or deformed spinal muscles.

Documentation and billing practices be sure you are meeting all the requirements to bill a spinal orthoses.

• Spinal Orthoses billed with HPCPCS L0450, L0454, L0621, L0625 and L0628 must be billed with the CG modifier if the brace is made of canvas, cotton, nylon or other non elastic material.

• Your documentation must show the brace is needed for one of the reasons listed above.

• The prescribing physician's chart notes must also document at least one of the three criteria have been met.

• Custom-fit codes must include documentation of the substantial modifications made to the brace. If there are not substantial modifications done then the Off the Shelf Code should be billed.

• In order to bill TLSO and LSO products to Medicare, there must be a written coding verification by the Pricing, Data Analysis, and Coding (PDAC) contractor (see Products Requiring PDAC Coding Verification.) You do not need a copy of the actual PDAC Coding Verification letter from the manufacturer, but you do need to verify the listing on  http://www.dmepdac.com/

If a spinal orthosis is delivered to a beneficiary in a hospital or SNF for use during the inpatient stay (e.g. for use after surgery and/or as part of the inpatient rehabilitation protocol), Medicare's payment to the facility covers the cost of the brace. The only exception to this rule is when the spinal orthosis is delivered to the beneficiary in the hospital within 48 hours of discharge and is intended for use at home.