SADMERC Coding Consensus & Rag Braces
Medicare contractors [the SADMERC and DMERCs] are now independently issuing opinions on what L-Codes apply to a variety of orthotic devices, based on information submitted by various manufacturers. In years past, AOPA has been asked to provide a list of such product-specific codes, but experts in the field found it impossible to accurately determine the biomechanical performance of specific devices, and hence the proper codes, by looking at faxes or line drawings and manufacturer's descriptions.
I recently received an unsolicited mailing from a "rag brace" company who markets prefabricated items that are primarily made from soft fabric. As part of their advertising package, they included a copy of the letter they received from the SADMERC advising how their products should be coded. One of their "me-too" products, which is very similar in external appearance to a competitive AFO designed by a Certified Orthotist, was featured in a flyer that screamed in capital italics: SADMERC APPROVED!
This claim caught my eye, along with the misspellings and incorrect terminology in their materials, as well as the very short lever arms in all their products suggesting that they would offer very limited biomechanical control. The ad sheet went on to assure that these products could be provided "without the fear of losing money!" and that they "have been given the appropriate codes for Medicare re-imbursement." [spelling, punctuation, bolding, and italics from advertisement]
These preposterous claims were all the more ludicrous because the SADMERC letter that was reproduced stated quite clearly:
"The assignment of a HCPCS code to this product should in no way be construed as an approval or endorsement of the product by SADMERC or Medicare, nor does it imply or guarantee reimbursement or coverage."
Their web site notes that these products are "distributed directly to hospitals"I. I wonder what the chances are that the hospitals will realize that when such products are delivered to inpatients, it is fraudulent to L-Code them since they fall under the DRG reimbursement?
AOPA has done a great job of educating practicing orthotists [and prosthetists] on the proper use of L-Codes; their two-day Coding & Billing Seminars are an outstanding resource in this regard and highly recommended. No one who's attended the AOPA seminars would believe the outlandish claims made by this company, or think that such written "assurances" would preclude the practitioners' legal liability. Click on www.aopanet.org for more information on future AOPA Seminars.