OIG Calls for Cuts in Medicare Rates for Back Orthoses

The OIG is calling on CMS to lower Medicare payment for certain back orthosis products, either by subjecting these products to the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program or by making an inherent reasonableness adjustment. This recommendation stems from the OIG’s findings that Medicare payment amounts far exceeded supplier acquisition costs for lumbar-sacral orthoses billed under L0631. Specifically, between July 2010 and June 2011, the average Medicare-allowed amount for L0631 was $919, compared to the average supplier acquisition cost of $191, resulting in Medicare paying an estimated $37 million more than supplier costs.  Please click here for more information

HCPCS Code L0430 – Invalid

Effective for dates of service on or after November 17, 2012, Healthcare Common Procedure Coding System (HCPCS) code L0430 (SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL, CUSTOM FITTED (DEWALL POSTURE PROTECTOR ONLY)) will be invalid for claim submission to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).  Products previously coded L0430 by the Pricing, Data Analysis and Coding (PDAC) contractor and posted to the Durable Medical Equipment Coding System (DMECS) will be end dated on November 17, 2012.  Please click here for more information.

Local Coverage Article for Ankle-Foot/Knee-Ankle-Foot Orthoses – Policy Article – Effective January 2013 (A19885)

Ankle-foot orthoses described by codes L1900, L1910-L1990 extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. The terminal height of an AFO shall be located between the proximal border of the gastrocnemius and the apex of the head of the fibula (a region that is generally 2-4 cm distal to the apex of the head of the fibula). These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle and ankle gauntlets described by codes L1902 – L1907.  To read the entire policy and guidelines, please click here