Orthotics Attract OIG Scrutiny

Orthotics Attract OIG Scrutiny

Medical claims for off-the-shelf orthotic devices have nearly doubled in the past several years, which has attracted the attention of the Department of Health and Human Services (HSS) Office of Inspector General (OIG). As part of its ongoing Work Plan, the OIG intends to examine claims to be sure that Medicare beneficiaries are receiving a proper encounter and referral within the 12 months prior to receiving orthotics.

The OIG has said it will audit claims for three off-the-shelf orthotic devices, in particular:

L0648 Lumbar-sacral orthosis, 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, off-the-shelf

L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf.

These three items were chosen due to high billing errors—in one case, in excess of 90 percent—found by a Medicare Administrative Contractor (MAC). Of particular concern was the lack of documentation of medical necessity in patients’ medical records to support the need for the orthotic device.

If your provider or facility bills for off-the-shelf orthotics (particularly any of the three listed, above), you may wish to perform a pre-emptive audit to be sure claims are supported by accurate documentation establishing medical necessity for the item(s).

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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