Audit Alert: CPAPs and Spinal Orthoses

On August 2, 2017, Performant Recovery, the National DMEPOS RAC, added Spinal Orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if coverage criteria outlined in the Local Coverage Determination (LCD) for Spinal Orthoses was met. Performant will review medical documentation provided to determine that services were reasonable and necessary.

Codes included in the audit are: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.

Per the LCD, a spinal orthosis (L0450 – L0651) is covered when it is ordered for one of the following indications:

  1. To reduce pain by restricting mobility of the trunk; or
  2. To facilitate healing following an injury to the spine or related soft tissues; or
  3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  4. To otherwise support weak spinal muscles and/or a deformed spine.

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.

 

On September 8, 2017, Performant Recovery announced that they added CPAPs billed without a diagnosis of Obstructive Sleep Apnea (OSA) to their approved issues list. According to their website, Performant Recovery will perform automated reviews of these claims to identify improper payments for claims for a CPAP with the missing diagnosis of OSA.

Codes included in the audit are: E0601

Per the LCD, an E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met.

A. The beneficiary has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.

B. The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

  1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
  2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
    • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
    • Hypertension, ischemic heart disease, or history of stroke.

C. The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.