L0631 and more
Tom Heckman
Description
Collection
Title:
L0631 and more
Creator:
Tom Heckman
Date:
4/2/2013
Text:
Hello List
Please excuse the length of this post. I always read, occasionally write, and
would like to get my money’s worth with the following observation / rant.
I am sure many of you are in the position of barely being able to keep up with
the (mostly negative) news regarding O and P because you are busy simply trying
to provide a prescribed service and be fairly reimbursed, or even reimbursed at
all. Thanks to all who are actively working on behalf of O and P.
We all know that at the heart of many of the issues / challenges the Accredited,
Licensed O & P community faces is: “Who is qualified to provide……?” and
therefore who is allowed to bill for …..?
We also know that this is not a simple issue, given the wide range of complexity
in the services and devices we provide as well as the wide range of medical and
quasi-medical providers with an interest in how this issue is resolved, or in
many cases, how it is left unresolved.
We also know that O and P providers represent a tiny percentage of those with a
dog in the fight.
We have had two similar cases recently. An elderly man came into our office with
a prescription from a Neurologist we know for a “lumbar support”. He also was
carrying a brace in a bag. He reported that he had received a phone call,
answered some questions, and the brace was delivered to his door. He stated he
was never able to use it. We took the opportunity to call Medicare for a “same
and similar” check and were told that about 10 months earlier Medicare had paid
a claim for a L0631. The patient was not sure who had sent him the brace, but we
told him to try to contact that company and to call Medicare to report that the
brace was unusable. We evaluated him and fit but did not issue a conventional
lumbosacral corset with stays which he stated was very supportive and which he
much preferred to the other brace. Later he called our office to state that
neither the supplier nor Medicare could “do anything for me” The name of the
supplier is US Healthcare Supply LLC and the brace is the VertaLoc LSO.
A second patient with compression fractures secondary to long term prednisone
use was referred by a Neurosurgeon with a prescription for a Jewett brace. The
brace required extensive modifications in order to fit and the patient was
ultimately seen three times including twice in a rehabilitation facility to
properly fit and adjust the orthosis. A claim was sent to Medicare and we
received a denial stating that the “equipment is the same or similar to
equipment currently being used”. We requested a redetermination including
practitioner notes, physician prescription, and the fact that the patient had
not informed us of any previous orthotic treatment. The redetermination was
denied, stating that Medicare had previously paid a claim for a L0631 to
Heritage Diabetic Supply, Inc. On their web site they offer a range of VertaLoc
products including the LSO. They are located in North Carolina and our patient
lives near Cleveland Ohio. If you will excuse me now I have to send a letter of
medical necessity, notarized physician progress notes, and manufacturer’s
invoice to support the fitting of a knee immobilizer on a patient following
surgery for a ruptured quadriceps tendon.
Tom Heckman CO, LO (Ohio)
Please excuse the length of this post. I always read, occasionally write, and
would like to get my money’s worth with the following observation / rant.
I am sure many of you are in the position of barely being able to keep up with
the (mostly negative) news regarding O and P because you are busy simply trying
to provide a prescribed service and be fairly reimbursed, or even reimbursed at
all. Thanks to all who are actively working on behalf of O and P.
We all know that at the heart of many of the issues / challenges the Accredited,
Licensed O & P community faces is: “Who is qualified to provide……?” and
therefore who is allowed to bill for …..?
We also know that this is not a simple issue, given the wide range of complexity
in the services and devices we provide as well as the wide range of medical and
quasi-medical providers with an interest in how this issue is resolved, or in
many cases, how it is left unresolved.
We also know that O and P providers represent a tiny percentage of those with a
dog in the fight.
We have had two similar cases recently. An elderly man came into our office with
a prescription from a Neurologist we know for a “lumbar support”. He also was
carrying a brace in a bag. He reported that he had received a phone call,
answered some questions, and the brace was delivered to his door. He stated he
was never able to use it. We took the opportunity to call Medicare for a “same
and similar” check and were told that about 10 months earlier Medicare had paid
a claim for a L0631. The patient was not sure who had sent him the brace, but we
told him to try to contact that company and to call Medicare to report that the
brace was unusable. We evaluated him and fit but did not issue a conventional
lumbosacral corset with stays which he stated was very supportive and which he
much preferred to the other brace. Later he called our office to state that
neither the supplier nor Medicare could “do anything for me” The name of the
supplier is US Healthcare Supply LLC and the brace is the VertaLoc LSO.
A second patient with compression fractures secondary to long term prednisone
use was referred by a Neurosurgeon with a prescription for a Jewett brace. The
brace required extensive modifications in order to fit and the patient was
ultimately seen three times including twice in a rehabilitation facility to
properly fit and adjust the orthosis. A claim was sent to Medicare and we
received a denial stating that the “equipment is the same or similar to
equipment currently being used”. We requested a redetermination including
practitioner notes, physician prescription, and the fact that the patient had
not informed us of any previous orthotic treatment. The redetermination was
denied, stating that Medicare had previously paid a claim for a L0631 to
Heritage Diabetic Supply, Inc. On their web site they offer a range of VertaLoc
products including the LSO. They are located in North Carolina and our patient
lives near Cleveland Ohio. If you will excuse me now I have to send a letter of
medical necessity, notarized physician progress notes, and manufacturer’s
invoice to support the fitting of a knee immobilizer on a patient following
surgery for a ruptured quadriceps tendon.
Tom Heckman CO, LO (Ohio)
Citation
Tom Heckman, “L0631 and more,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/234992.
