Re: L0637 requirements
Juan Chow LO
Description
Collection
Title:
Re: L0637 requirements
Creator:
Juan Chow LO
Date:
3/3/2022
Text:
Thank you all for your responses. What was clear from the call with
Medicare is that they are set in their mind on what they are going to
decide, which is deny the claim, they were not hired to approve things.
It is also weird that some of the audits were approved with the same
information provided. This means that one auditor will approve the claim
while another would deny it. The person we talked to on the phone said
that the ones that we passed she would have denied them all. It all
seems like a game, roll the dice see what happens… I wish Medicare would
simplify these things like some Worker’s Comp states do by adopting ODG
treatment guidelines where everything is spelled out to a T on what is
required.
Anyway here are some of the responses that were sent, again thank you
very much.
*
Those modifications require education and training. I would counter
that reasoning.
*
Their response is essentially the same as what we have heard when we
sat on a Medicare education webinar and asked a similar question. We
are not in a competitive bid area so rarely have that issue, but we
have determined for the most part the OTS code is what we bill
because there is no clear indicator as to what they would pay for as
substantially modified. I personally agree that what they consider
OTS and modifiable by the patients is ridiculous, as I am not sure
about other patients, but many of ours end up coming in for
adjustments on OTS braces because they put them on upside down
and/or backwards. I could just imagine what would happen if we asked
them to use a heat gun and bend the supports....
*
I would recommend that you document what tool you use in addition to
what modification you are doing - that will go a long way towards
proving that a regular person could not do it - most people don't
have a heat gun or a bending iron at their house. And then when they
deny for no custom fit, appeal it. I find the reconsideration phase
to be much more reasonable than the original audit.
*
This is crazy. I would be venting also
*
The only time we have won these types of audits is when we measure
the device and document angles or degrees of lordosis/kyphosis,
girth of abdomen etc. then write (quite) literally a page on how the
orthosis was modified, ( in addition to the medical necessity,
medical history, and education) and what the end condition of the
orthosis, angles or degrees of lordosis, girth of abdomen of the
orthosis, what tools were used and why the average person does not
have access to these in their tool box in the garage. If you are
using a back brace which has a kydex back panel, a high powered hair
dryer will heat that up enough to mold it so just using a heat gun
is not enough to justify custom fit, you have to prove that it takes
medical knowledge to know to make the changes and why they are
important. We find that using bending irons are your best bet for
tools which people won't have in their garages, use these and
document how and why you used them. Anything with scissors doesn't
count. Basically if you can buy it at a hardware store then you
cannot count it as a custom modification what only you can do.
*
In your CHART NOTE, all of this must be in the initial chart note,
should be 2-3 pages long if you're going to win this. That is how
detailed it needs to be. Think writing an instruction manual for a
3rd grader with the why behind it. The ones we have won have been at
least 2 full pages long, paragraph long notes or letters will not
cut it. It also helps to put IN THE CHART NOTE what textbooks back
up your logic of the medical need for the changes to the orthosis.
Think War and Peace not little golden book.
*
Using the above I have had denials overturned at the ALJ. You will
never have these overturned at the lower levels, as they are paid to
deny claims. Also remember you don’t have a snowballs chance in hell
if your chart notes don't have ALL of this. You can't write a letter
later and explain it. Has to be done when you chart.
*
Total bullshit !
*
We're in a competitive bid area as well. What we suspected is that
Medicare has the numbers prior to the bid going into effect that
breaks down how many ots vs custom fits were provided over the
years. We rarely would do a custom fit 637 in the past, so obviously
a red flag would be set off if all of a sudden we're classifying all
patients as requiring a custom fit spinal orthosis. Further I wonder
if Medicare is looking for objective information, such as magnitude
of lordosis measured by a goniometer, as they require in the K/AFO LCD.
*
I would be curious to hear any responses if anyone has come up with
useful verbage to use in the notes. I feel your pain as most
patients do not understand the simple directions on these braces. I
had one patient sent to me for an LSO. When he saw me adjust it,
his comment was, Oh I threw out a brace a company mailed to me
because it was too small to fit on me when I took it out of the box;
I didn't know you could do that to it!
*
There is a word difference in the Medicare Policy Article. It does
use the term molded (with or without heat) in the custom fitted
definition and only uses molding in the OTS. My understanding would
be that if the patient didn't have the knowledge (about why their dx
required a specific modification) and the tools to make the
adjustment, then it would be custom fitted. If it requires bending
irons rather than just your hands to make an adjustment or if it
requires a heat gun not a hair dryer to heat the plastic hot enough,
then that would be sufficient. I would highly recommend using the
CGS Connect program. /CGS Connect™/ is a unique concierge-level
service offered exclusively for Jurisdiction C suppliers seeking
professional review and evaluation of pre-claim documentation before
submitting an initial claim to Medicare. CGS Connect™ is a
voluntary program that provides you with a higher level of assurance
that your supporting documentation meets the necessary requirements
to process your claim for payment consideration. L0650 is an option
to submit to CGS Connect.
o
Here is the specific Policy requirements from the Medicare webpage:
o
OTS items require minimal self-adjustment for fitting at the
time of delivery for appropriate use and do not require
expertise in trimming, bending, and molding, assembling, or
customizing to fit an individual.
o
Classification as custom fitted requires more than minimal
self-adjustment at the time of delivery in order to provide an
individualized fit, i.e., the item must be trimmed, bent, molded
(with or without heat), or otherwise modified resulting in
alterations beyond minimal self-adjustment
> Juan Chow LO
Medicare is that they are set in their mind on what they are going to
decide, which is deny the claim, they were not hired to approve things.
It is also weird that some of the audits were approved with the same
information provided. This means that one auditor will approve the claim
while another would deny it. The person we talked to on the phone said
that the ones that we passed she would have denied them all. It all
seems like a game, roll the dice see what happens… I wish Medicare would
simplify these things like some Worker’s Comp states do by adopting ODG
treatment guidelines where everything is spelled out to a T on what is
required.
Anyway here are some of the responses that were sent, again thank you
very much.
*
Those modifications require education and training. I would counter
that reasoning.
*
Their response is essentially the same as what we have heard when we
sat on a Medicare education webinar and asked a similar question. We
are not in a competitive bid area so rarely have that issue, but we
have determined for the most part the OTS code is what we bill
because there is no clear indicator as to what they would pay for as
substantially modified. I personally agree that what they consider
OTS and modifiable by the patients is ridiculous, as I am not sure
about other patients, but many of ours end up coming in for
adjustments on OTS braces because they put them on upside down
and/or backwards. I could just imagine what would happen if we asked
them to use a heat gun and bend the supports....
*
I would recommend that you document what tool you use in addition to
what modification you are doing - that will go a long way towards
proving that a regular person could not do it - most people don't
have a heat gun or a bending iron at their house. And then when they
deny for no custom fit, appeal it. I find the reconsideration phase
to be much more reasonable than the original audit.
*
This is crazy. I would be venting also
*
The only time we have won these types of audits is when we measure
the device and document angles or degrees of lordosis/kyphosis,
girth of abdomen etc. then write (quite) literally a page on how the
orthosis was modified, ( in addition to the medical necessity,
medical history, and education) and what the end condition of the
orthosis, angles or degrees of lordosis, girth of abdomen of the
orthosis, what tools were used and why the average person does not
have access to these in their tool box in the garage. If you are
using a back brace which has a kydex back panel, a high powered hair
dryer will heat that up enough to mold it so just using a heat gun
is not enough to justify custom fit, you have to prove that it takes
medical knowledge to know to make the changes and why they are
important. We find that using bending irons are your best bet for
tools which people won't have in their garages, use these and
document how and why you used them. Anything with scissors doesn't
count. Basically if you can buy it at a hardware store then you
cannot count it as a custom modification what only you can do.
*
In your CHART NOTE, all of this must be in the initial chart note,
should be 2-3 pages long if you're going to win this. That is how
detailed it needs to be. Think writing an instruction manual for a
3rd grader with the why behind it. The ones we have won have been at
least 2 full pages long, paragraph long notes or letters will not
cut it. It also helps to put IN THE CHART NOTE what textbooks back
up your logic of the medical need for the changes to the orthosis.
Think War and Peace not little golden book.
*
Using the above I have had denials overturned at the ALJ. You will
never have these overturned at the lower levels, as they are paid to
deny claims. Also remember you don’t have a snowballs chance in hell
if your chart notes don't have ALL of this. You can't write a letter
later and explain it. Has to be done when you chart.
*
Total bullshit !
*
We're in a competitive bid area as well. What we suspected is that
Medicare has the numbers prior to the bid going into effect that
breaks down how many ots vs custom fits were provided over the
years. We rarely would do a custom fit 637 in the past, so obviously
a red flag would be set off if all of a sudden we're classifying all
patients as requiring a custom fit spinal orthosis. Further I wonder
if Medicare is looking for objective information, such as magnitude
of lordosis measured by a goniometer, as they require in the K/AFO LCD.
*
I would be curious to hear any responses if anyone has come up with
useful verbage to use in the notes. I feel your pain as most
patients do not understand the simple directions on these braces. I
had one patient sent to me for an LSO. When he saw me adjust it,
his comment was, Oh I threw out a brace a company mailed to me
because it was too small to fit on me when I took it out of the box;
I didn't know you could do that to it!
*
There is a word difference in the Medicare Policy Article. It does
use the term molded (with or without heat) in the custom fitted
definition and only uses molding in the OTS. My understanding would
be that if the patient didn't have the knowledge (about why their dx
required a specific modification) and the tools to make the
adjustment, then it would be custom fitted. If it requires bending
irons rather than just your hands to make an adjustment or if it
requires a heat gun not a hair dryer to heat the plastic hot enough,
then that would be sufficient. I would highly recommend using the
CGS Connect program. /CGS Connect™/ is a unique concierge-level
service offered exclusively for Jurisdiction C suppliers seeking
professional review and evaluation of pre-claim documentation before
submitting an initial claim to Medicare. CGS Connect™ is a
voluntary program that provides you with a higher level of assurance
that your supporting documentation meets the necessary requirements
to process your claim for payment consideration. L0650 is an option
to submit to CGS Connect.
o
Here is the specific Policy requirements from the Medicare webpage:
o
OTS items require minimal self-adjustment for fitting at the
time of delivery for appropriate use and do not require
expertise in trimming, bending, and molding, assembling, or
customizing to fit an individual.
o
Classification as custom fitted requires more than minimal
self-adjustment at the time of delivery in order to provide an
individualized fit, i.e., the item must be trimmed, bent, molded
(with or without heat), or otherwise modified resulting in
alterations beyond minimal self-adjustment
> Juan Chow LO
Citation
Juan Chow LO, “Re: L0637 requirements,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255827.
