Code Correctly and Get Paid: Spinal Orthoses
By Virginia Torsch, AOPA Government Affairs Department

One of the most important things we do at AOPA is help you sort through CMS medical policy so you can get paid for the devices you provide. This article describes the three basic types of spinal orthoses, reviews the details of their descriptions and offers guidelines for whether to bill the hospital, skilled nursing facility or DME MAC.

There are three basic types of spinal orthoses, which are coded and described by the section(s) of the spine they support:

•    Thoracic-lumbar-sacral orthoses (TLSOs) are described by codes L0450-L0490 and L0491-L0492
•    Lumbar orthoses (LOs) are described by codes L0625-L0627
•    Lumbar-sacral orthoses (LSOs) are described by L0628-L0640.

The code descriptors for spinal orthoses used to be a little vague about the type of brace they described. After a failed attempt by the Office of the Inspector General (OIG) to combat a couple of cases of suspected fraud because of this vague wording, the Centers for Medicare and Medicaid Services (CMS) decided to make the spinal orthoses code descriptors much more detailed. In 2003, CMS modified the descriptors for the TLSO codes. In 2004, it created new and much more detailed codes for LOs and LSOs.

Is it covered? The basics
TLSOs, LOs and LSOs are covered when used to treat one of the following indications:

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

If none of these indications exist, the spinal orthosis will be denied as not medically necessary.

Is it covered? The details
According to Medicare, TLSOs, LOs and LSOs have the following characteristics:

•    They are used to immobilize the specified areas of the spine  
•    They have an intimate fit and are generally designed to be worn under clothing
•    They are not specifically designed for patients in wheelchairs.

Medicare also defines spinal orthoses as braces that control movement of the trunk and the vertebrae in one or more of the following planes:

•    Lateral/flexion in the coronal/frontal plane. In these devices, a rigid panel in the mid-axillary line controls movement.
•    Flexion or extension in the sagittal plane. In these devices, a rigid posterior panel controls movement.
•    Axial rotation in the transverse plane. In these devices, one of the following controls movement:
        -rigid panel in the upper sternal area that is an integral part of the anterior shell
        -rigid panel in the upper sternal area attached to the rigid abdominal or posterior panel
        -rigid extensions from a rigid posterior panel to the upper anterior chest on both sides.

If a spinal brace does not control one or more of these planes of motion or does not provide intracavitary pressure, Medicare will not consider it a spinal orthosis.

Defining body jackets
Some codes for TLSOs (L0458-L0464, L0480-L0490, L0491 and L0492) and LSOs (L0639-L0640) apply only to orthoses that are body jackets.

To meet Medicare’s definition of a body jacket, the orthosis has to have a rigid plastic shell that circles the trunk with overlapping edges and stabilizing closures, and the entire circumference of the shell must be made of the same rigid material.

More TLSO specifications
TLSOs are more specifically described in the medical policy article as spinal orthoses that have the posterior portion of the brace extending from the sacrococcygeal junction to just below the scapular spine. The anterior portion of the brace must extend from at least the symphysis pubis to the xyphoid. The anterior portion of some TLSOs may extend up to the sternal notch.

Prefabricated vs. custom fabricated
In addition to describing the specific characteristics of spinal orthoses, CMS has explained in detail the difference between a prefabricated spinal orthosis and a custom fabricated orthosis.

Prefabricated orthoses
CMS defines a prefabricated orthosis as one manufactured with no
specific patient in mind. The orthosis is preformed, generally conforming to the body, and then trimmed, bent, molded or otherwise modified to fit a specific patient.

An orthosis is still considered prefabricated even if it requires straps, lining or other finishing work. An orthosis assembled from prefabricated components is also considered prefabricated. In general, any orthosis that doesn’t fit the definition of a custom fabricated orthosis is considered prefabricated.

Custom fabricated orthoses
CMS defines a custom fabricated orthosis as one individually made for a specific patient. The practitioner starts with basic materials such as plastic, metal, leather or cloth, and then cuts, vacuum forms, bends or otherwise modifies the material to fit the patient. Custom fabricated spinal orthoses have their own specific codes: L0629, L0632, L0634, L0636, L0638, L0640, L0452 and L0478-L0486.

A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis. Its fabrication involves one of the following:

•    Taking an impression of a specific body part (usually by a plaster or fiberglass cast) and using this impression to make a positive model
•    Using detailed measurements of the patient’s torso to modify a positive model, selected from a large range of models, so that it conforms to the patient
•    Making a digital image of the patient’s torso using computer software (such as CAD-CAM) which then directs the carving of a positive model. (Note: Medicare will not cover the additional expense of using CAD-CAM technology.)

The orthosis is then individually fabricated and molded over the positive model of the patient.

Who to bill
Medicare has given specific rules about who to bill for spinal orthoses provided to patients in a hospital or a skilled nursing facility (SNF).

If you are providing the spinal orthosis to a patient prior to a hospital or a Part A SNF stay, and the patient will use the orthosis in the hospital or SNF, bill the hospital or the SNF. Do not submit the bill to your DME Medicare Administrative Carrier (DME MAC); it will be denied as noncovered under Medicare Part B.

The exception is the following situation, commonly called “the two-day rule”: If the orthosis is provided within 48 hours of discharge from the hospital or SNF and is only to be used at home, bill your DME MAC. (You cannot apply the two-day rule to spinal orthoses provided to patients for use right after spinal surgery.)
A recent CMS transmittal identified one other circumstance where you bill the DME MAC. If you receive a verbal order for a custom fabricated spinal orthosis while the patient is still at home, but the patient is admitted to a hospital or SNF before you complete the device, bill your DME MAC. In this case, CMS considers that medical necessity for the spinal orthosis occurred while the patient was still at home under Medicare Part B.

Get paid for your work
These are the major provisions of medical policy on spinal orthoses that you need to know to have your claims paid. CMS and the DME MACs also occasionally publish transmittals and bulletins amplifying the provisions in the LCDs and accompanying policy articles, so it is wise to pay attention to those, too. These bulletins and transmittals are published on your DME MAC’s Web site. You may also sign up on each site for e-mail notification of news. The sites are:

•    Jurisdictions A and B 
•    Jurisdiction C
•    Jurisdiction D

Remember that AOPA staff is committed to keeping you up to speed on this information so you
can be reimbursed appropriately for your work.

Virginia Torsch is the assistant director of government affairs for the American Orthotic & Prosthetic Association (AOPA). AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals.

Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession.

Questions? Call (571) 431-0876 or visit www.AOPAnet.org.