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| Arthritis Kits TriCenturion, the Jurisdiction B DME Program Safeguard Contractor (PSC), has identified a number of suppliers who are marketing and providing what are often described as Arthritis Kits . These kits are advertised to beneficiaries as including multiple upper limb (shoulder, elbow, wrist, hand), lower limb (knee, ankle), and spinal (neck, back) orthotics . They sometimes include a heating pad or heat lamp. The advertisements claim that these kits are designed to eliminate or reduce arthritic pain. They entice beneficiaries and obtain physician orders by stating that the items are Medicare Approved and that there will be no cost to the beneficiary (if he/she has a Medicare supplement plan). Several problems have been identified in cases that the PSC has investigated. First, many of the items are billed using incorrect HCPCS codes. Various types of arthritis gloves are billed as hand orthoses. The appropriate coding for these is usually A9270 (noncovered item or service). Other elastic or flexible fabric products are billed using L codes that describe rigid orthoses. If manufacturers or suppliers have any questions concerning the correct coding of a product, they should consult the DMECS Product Classification List on the Pricing, Data Analysis, and Coding contractor (PDAC) web site – www.dmepdac.com. If the product is not listed on the web site, they can contact the PDAC for a Coding Verification Review. Second, many of the items are statutorily noncovered by Medicare – i.e., they do not meet the definition of a Part B benefit category. In order to be covered as braces, items must be rigid (or) semi-rigid devices that are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. (Internet-Only Manual, 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 130) CMS has recently clarified that elastic items do not meet the statutory definition of a brace. Finally, in almost all cases, documentation does not support the medical necessity for the items. There must be a detailed written order for each item that is separately billed to Medicare that is signed and dated by the treating physician and received by the supplier prior to claim submission. There must be information in the patient s medical record (e.g., physician office notes) from prior to the date of delivery that clearly supports the medical necessity for each item. A simple diagnosis of arthritis or other general statement is not sufficient. The history and physical examination must document the severity of the condition and the need for each item. Since it would rarely be medically necessary to order multiple orthoses at the same time, the greater the number of items provided, the more detailed is the documentation that would be required. For additional information concerning documentation requirements, suppliers should consult the Supplier Manual on the National Government Services, Jurisdiction B DME MAC web site, or the Medicare Program Integrity Manual (Internet-Only Manual 100-08). Suspected fraud and abuse may be reported by calling the National Government Services Customer Care Contact Center at 866-590-6727. |
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