Prepayment Review for O&P HCPCS Codes in Jurisdiction D

Following up on the Inspector General report from 2011, the following HCPCS codes were reviewed as part of a Comprehensive Error Rate Testing (CERT) analysis and have now been put on prepayment review for DME MAC Jurisdiction D. 

L0631 – Lumbar-sacral orthosis (LSO), 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, includes fitting and adjustment
L0637 – Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting & adjustment
L8030 – Breast prosthesis, silicone or equal, without integral adhesive
L4360 – Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting & adjustment
L1960 – Ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated
L1970 – Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated

Evaluation of the claims will require additional documentation after providers submit claims pertaining to the codes listed above.  The Additional Documentation Request (ADR) will ask for detailed specifics if the item billed complies with the existing reasonable and necessary criteria. Failure to respond to the ADR within 45 days will result in the claim being denied. 

Be sure to review the most up-to-date LCD information on the HCPCS codes listed above if you are currently billing in Jurisdiction D. (From Noridian Admin Services)

Spinal Orthoses: TLSO and LSO L11459 & A23846
External Breast Prosthesis L11569 & A19833
Ankle-Foot/Knee-Ankle-Foot Orthosis L142 & A19800 

 

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