“I have had a RAC audit for a L1951 (from performant) claiming an overpayment stating, “the custom- fitted orthosis did not include a detailed description of the necessary modifications.” L1951 is a prefab which does not require modifications. Where can I go to get any documents (Medicare preferred) stating that L1951 is prefab and as such does not require modifications to respond to this demand?”
A RAC audit is not a pleasant experience. They are all about the dollars. A private, independent company performs the audit, and they are reimbursed by a percentage of the amount that they find to have been inappropriately billed to the Medicare Administrative Contractor and reimbursed to the provider. Since in this scenario a DME item is at issue, the contractor is specifically a Durable medical Equipment Regional Contractor.
The HCPCS Level II code at issue is L1951 which is defined as the following: ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT. The point of contention appears to be “includes fitting and adjustment.”
Apparently, the RAC auditor is claiming that L1951 should not have been reimbursed based upon the fact that “the custom fitted orthotic did not include a detailed description of the necessary modifications.”
Obviously, L1951 is not the same type of OTC device that is described by HCPCS Level II code L4360 which is defined as the following: WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE. Clearly, this device is an OTC device that needs to be specifically “customized to fit” the patient in question. The customized fitting of the AFO needs to be specifically documented within the medical record. The big question is: Is the RAC auditor correct that “the custom- fitted orthosis did not include a detailed description of the necessary modifications?”
To address the issue at hand, it is important to access the following DMERC LCD L33686 Ankle-Foot/Knee-Ankle-Foot Orthoses and the associated policy article A52457. It is especially important to access the article.
Within the article the following is found:
“Off-the-shelf (OTS) orthotics are:
• Items that are prefabricated.
• They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
• 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.
• This fitting does not require expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary.
The term “minimal self-adjustment” is defined at 42 CFR §414.402 as an adjustment the beneficiary, caregiver for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. See “more than minimal self-adjustment” definition below for additional information.”
Based upon the above information, I feel that the RAC auditor is incorrect in their assessment that the necessary documentation that includes a “detailed description” of the necessary modifications is required. It appears that it is not.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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