Results of Widespread Prepayment Review of Claims for Lumbar-Sacral Orthoses, HCPCS Codes L0631/L0637

DME MAC Jurisdiction A has completed the widespread prepayment review of claims for Lumbar-Sacral Orthoses (HCPCS codes L0631 and L0637). These findings include claims processed primarily from June 2015 through August 2015.

The review involved prepayment complex medical review of 1,068 claims submitted by 357 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 500 (47%) of the claims. For the remaining 568 claims, 17 claims were allowed and 551 claims were denied resulting in a claim denial rate of 97%. The overall CDR was 95.5%.

This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The overall Charge Denial Rate (CDR) is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed). The previous quarterly findings covered the period of March 2015 through May 2015 and resulted in a CDR of 81.8%.

Charge Denial Rate Historical Data

The following graph depicts the Charge Denial Rate from previous review periods to current:

Review Period Charge Denial Rate
April 2014 – August 2014 87.6%
August 2014 – December 2014 82.3%
December 2014 – February 2015 82.0%
March 2015 – May 2015 81.8%
June 2015 – August 2015 95.5%

Primary Reasons for Denial

Based on review of the documentation received, the following are the reasons for denial. Note that the percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also note that claims can be denied for multiple reasons therefore the percentages of reviews may not add up to 100%:

Detailed Written Orders Issues

  • Denied claims were missing a Detailed Written Order (DWO) (10.8%)
  • Denied claims included an incomplete DWO (26%)
    • DWOs submitted were not legible and/or did not list beneficiary name (2%)
    • DWOs missing start date and/or signature date (2.5%)
    • DWOs were missing a detailed description of the requested Lumbar Sacral Orthotic (s) The detailed description in the written order may be either a narrative description or a brand name/model number (10%)

Medical Record Documentation Issues

  • Denied claims missing the clinical documentation to support medical necessity (6%)
  • Denied claims upon review of clinical documentation (30%)
    • Medical documentation was not authenticated by the clinician conducting the exam (6%)
    • Clinician notes submitted did not support medical necessity. The documentation submitted did not demonstrate the treatment of an illness or injury to improve functioning of the spine or trunk on the body (24%)

Proof of Delivery Issues

  • Denied claims were missing the Proof of Delivery (POD) (9%)
  • Proof of Delivery (POD) included delivery documentation was missing required elements (8%)
    • Delivery documentation (Method 1) did not include signature of beneficiary or beneficiary’s representative; unable to determine if beneficiary received items billed (1%)
    • Dates of service do not match shipping/receipt dates for items, as defined within LCD (L33790) (1%)
    • Delivery documentation does not include delivery address (3%)
    • Delivery documentation does not specify the requested Lumbar-Sacral-Orthosis, and it is unclear from the description which orthotic is being delivered. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary. (3%)
Read the full release here: http://myemail.constantcontact.com/DME-MAC-JA-News—Results-of-Widespread-Prepayment-Review-of-Claims-for-Lumbar-Sacral-Orthoses–HCPCS-Codes-L0631-L0637.html

Pharmacogenetics and Pain Management – Clinical Use and Interpretation of the Common Pharmacogenetic Tests

In recent years, pharmacogenetic testing has become more common in pain management. During this time, a few cytochrome P450 (CYP450) enzymes have been identified as being particularly important to the metabolism of certain pharmaceutical agents commonly used in pain treatment, such as opioids, antidepressants, and anti-inflammatory agents.

More recently, 2 non-cytochrome P450 “pharmacodynamic” genetic tests have been identified that help explain opioid dosage requirements in pain patients. The first measures, opioid mu receptor 1 (OPRM1), which determines the ability of opioids to bind to the mu opioid receptor site. The other measures catechol-o methyltransferase (COMT), the enzyme that degrades catecholamines in the central nervous system.

All pain practitioners who prescribe opioids should know that a patient with an OPRM1 with a low sensitivity rating and/or a COMT with a high activity rating likely will require a higher opioid dose than normal to obtain relief from a severe pain problem.

This article presents an up-to-date status and review of the pharmacogenetic markers that have relevance to pain practice. Read the full article here: http://www.practicalpainmanagement.com/resources/diagnostic-tests/pharmacogenetics-pain-management

Exercise & Lifestyle Tips to Reduce Back Pain

Back pain is often a result of the aging process for many people, but there are steps you can take to keep your back strong and healthy.

“As you age, your back undergoes degenerative changes,” says Garrett Helber DO. Most people refer to these changes as arthritis, which include disk degeneration, spinal canal narrowing and enlargement of the joints of the spine. As a result, some people may experience pain, although there are many that do not,” he says.

How posture affects back health

“It can also contribute to issues with the muscles surrounding the spine, including the neck,” says Dr. Helber. “Good posture helps to minimize the stress on your spine and on the surrounding muscles, which helps to reduce pain in the long term.”

Some additional posture tips:

  • Sit up with your back straight and your shoulders back. Your buttocks should touch the back of your chair.
  • Distribute your body weight evenly on both hips.
  • Keep your knees even with or slightly higher than your hips (use a foot rest or stool if necessary).
  • Do not cross your legs; keep your feet flat on the floor.
  • Adjust your chair height and work station so you can sit up close to your work. Rest your elbows and arms on your chair or desk, keeping your shoulders relaxed.

Exercises to strengthen your back

Fortunately, there are also exercises you can do to stretch and strengthen your back and help avoid or reduce pain. “Using a core stability ball instead of a chair while sitting at your desk will activate and strengthen back muscles while working,” Dr. Helber says.

Outside of work, Dr. Helber recommends these exercises:

  • Superman: Lie on your stomach on a flat surface and raise both your arms and your legs at the same time as though you are flying. Hold the position for five seconds. Then repeat 10 times. This helps strengthen your lower back.
  • Pelvic tilt: Lie on your back with your knees bent. In this relaxed position, the small of your back will not touch the floor. Tighten your abdominal muscles so that the small of your back presses flat against the floor. Hold for five seconds, then relax. Repeat three times and gradually build to 10 repetitions.
  • Knees-to-chest: Lie on your back with both legs straight. Bring one knee up to your chest, pressing the small of your back into the floor (see pelvic tilt). Hold for five seconds and repeat five times. Repeat exercise with the other leg.
  • Back extension stretch: Lie on your stomach. Use your arms to push your upper body off the floor. Hold for five seconds. Let your back relax and sag. Repeat 10 times.

Lifestyle changes can decrease back pain

There are three main things you can do to strengthen your back and decrease pain, says Dr. Helber:

  • Avoid smoking or using nicotine products.
  • Maintain a healthy body weight.
  • Stay active and perform the exercises outlined above.

When it comes to keeping your back strong, good habits will serve you well, especially proper posture and exercise.

Read the full article here: http://health.clevelandclinic.org/2015/09/got-back-pain-try-superman-3-exercises/

Nonpharmacologic Treatment for Long-Term Neck Pain

A Swedish study is set to analyze the effect of massage and exercise therapy on subacute and long-lasting neck pain, which is a pesky, costly, and potentially debilitating condition. According to the researchers, between half and three quarters of people with current neck pain will report neck pain again one to five years later. In addition, half of all work-related injuries reported in Sweden involve disorders of the muscles and joints. This makes the socio-economic impact of neck pain extensive, and the overall costs in terms of lost productivity and quality of life very high.

The upcoming study will be a randomized controlled trial in which at least 600 study participants with subacute or long-lasting nonspecific neck pain will be recruited and randomly allocated to one of four treatment arms: massage therapy; exercise therapy; exercise therapy combined with massage therapy; and simple advice to “stay active.” Study participants are being recruited through advertising with a mix of traditional and online marketing channels, and the research will use a combination of in-person and online interventions and measurements – including web-based self-report questionnaires at seven, 12, 26 and 52 weeks after inclusion.

The primary outcomes are a clinically important improvement in pain intensity and pain-related disability at follow-up, measured with a modified version of the Chronic Pain Questionnaire (CPQ). The secondary outcomes are global improvement, health-related quality of life (EQ-5D), use of sick leave, use of pharmacologic therapy, and overall healthcare utilization. Adverse events will be measured by questionnaires at return visits to the clinic. Neck pain intensity and pain-related disability will be measured every week for one year.

“We hypothesize that massage and physical exercise have beneficial effects on subacute and long-lasting neck pain because that is the case with chronic low back pain,” the study authors observed, citing earlier research. “There is scientific evidence for the effect of massage on nonspecific low back pain, especially when combined with exercises and education. Physical exercise has been shown to be efficient in reducing the pain and disability in long-lasting low back pain and to reduce work absenteeism.”

Participants randomized to exercise therapy will receive instruction and support on physical exercises in 30-minute sessions (total visit time 45 minutes) at the study center. The primary focus is on strengthening of the deep neck muscles and shoulder muscles, as well as strengthening and passive stretching of breast muscles and jaw muscles. The delivery method is one-on-one, and the only exercise equipment used is a rubber band (for the shoulder muscle strengthening). Participants randomized to the “advice to stay active” arm will get guidance and support from a therapist on staying active and on pain-coping strategies, according to guidelines and evidence-based reviews.

Read more: http://www.hcplive.com/medical-news/stay-tuned-nonpharmacologic-treatment-of-long-term-neck-pain#sthash.OMCixVwY.dpuf

How to Treat Patellofemoral Pain Syndrome, Otherwise Known as Runner’s Knee

In medical terminology, “runners knee” is called patellofemoral pain syndrome (PFPS). It is a problem that responds very well to physiotherapy treatment and there is a reasonable amount of research evidence behind what we do. The pain arises from around or under the patella (knee-cap) and can be as a result of it not tracking properly in its groove. There are some common risk factors that can affect how the patella tracks.

How to treat it?

There are a lot of treatment options for patellofemoral pain and it normally responds well to physiotherapy. The treatment is not prescriptive and will depend on where you are in your training and why you have developed symptoms. The main treatment options are as follows :

  • Education: understanding why you came to have this injury will help to avoid recurrence. This is a key part of the treatment. It is important to look back and see if you have made any training errors related to load or training surface.
  • Rest or reduction in activity: mostly there will need to be some alteration in your running activity. If you are lucky, it might just be cutting this back a little but if the pain is too severe, you will need to rest to allow the irritation to settle. If you are training for a particular event then it is important that you keep up cardiovascular training where possible but using an alternative method that does not aggravate the symptoms until you are back to running.
  • Taping: there is evidence to suggest that taping the knee can help in the short term to relieve pain and may allow you to continue running and start exercising the muscles in the thigh earlier. Some patients also find it helpful to use a knee brace.
  • Correcting any biomechanical issues: this will involve assessing how you move, and using mirrors and videos to help to teach you new movement patterns. It is likely to involve improving glutes and quads strength and activation, and sometimes muscle stimulators may also be used to make changes more quickly if you are very weak. There are a number of different exercises that target these muscles, including squats, single leg squats and lunges. However, pain is a big inhibitor to muscle function so it is important that the exercises are comfortable. It is worth understanding that doing these exercises without appropriate instruction and supervision may worsen the condition.
  • Soft-tissue release and stretching: each person will present differently. Some people have tightness in their calves, quads and hamstrings, and therefore soft-tissue release and stretching may be appropriate. Mobilisations to the ankle and around the kneecap may also be used. However, issues in flexibility as a primary factor are probably less common than strength and control issues with patellofemoral pain. This means that stretching/rollering alone is unlikely to resolve your symptoms.
  • Orthotics: if you do roll your feet in excessively then you may need an orthotic device – an insole you insert into your shoe to help support your arch. This can be bought off the shelf or custom-made by a podiatrist. If your feet only roll in a little then you may be able to improve the position of the foot enough with the correct pair of trainers.
  • Anti-inflammatories: if you are unable to carry out normal functional activities without significant pain, then a course of anti-inflammatories may be appropriate. If you are in training and have a race coming up, then – with the advice of a medical professional – it may be appropriate to run with some pain and use anti-inflammatories to reduce the symptoms. This course of action obviously risks masking the pain and should therefore be discussed with your doctor or therapist. If you choose to continue to train, despite pain, to compete in a race, it is important that you allow yourself time post-race to address thoroughly the issues surrounding why you developed the pain in the first place.

Read the full article here: http://www.theguardian.com/lifeandstyle/the-running-blog/2015/sep/30/running-into-problems-runners-knee-physiotherapist

Study: Back Pain Patients Seek Pain Relief First, Mobility Second

Pain relief is a greater concern than mobility for people with a common form of lower back pain known as lumbar spinal stenosis, a new study indicates.

When asked to choose between a treatment that would reduce discomfort and one that would help them stand and walk, the vast majority of patients wanted to ease their pain, the researchers found.

“There has long been a debate in the medical community over striking the right balance between pain relief and physical function,” said the study’s lead author, Dr. John Markman, director of the Translational Pain Research Program in the University of Rochester Department of Neurosurgery in Rochester, N.Y.

“While physicians have leaned toward the need to increase mobility, this study shows that patients have a clear preference for pain relief,” Markman said in a university news release.

The researchers explained that lumbar spinal stenosis occurs when the vertebrae, discs, joints and ligaments of the spinal column break down, causing the spinal canal to narrow. This compresses nerve roots, which leads to pain, tingling and numbness in the lower back, buttocks and legs. Most patients with this condition are in pain when they stand or walk.

Surgery can help reduce pain and help people move around with greater ease, but not all patients are candidates for a surgical procedure. Steroids injected into the spinal column can bring pain relief, but only temporarily.

The study’s authors focused on nearly 270 patients who had trouble standing and walking and suffered from chronic back pain associated with lumbar spinal stenosis. The participants were asked to choose between a therapy that reduced their pain and one that would enable them to stand and walk. Nearly 80 percent of the patients said they would rather have relief from their pain than greater mobility, the study published recently in Neurology found.

“Even the patients who could not stand long enough to pick up a letter from their mailbox or wash the dishes after dinner chose pain relief,” said Markman.

The authors pointed out patients are playing a greater role in setting new standards for pain relief, demanding new medications that are both safe and effective. “This study convincingly demonstrates the need to prioritize pain relief because that is what patients want,” Markman said.

Read more here: http://consumer.healthday.com/bone-and-joint-information-4/backache-news-53/pain-relief-top-concern-for-those-with-lower-back-pain-703179.html

NIH Panel: Opioid Use Calls for Individualized Treatment for Americans in Pain

Until more research is conducted on the safety and effectiveness of opioid painkillers, the health care community should focus on individualized care for the one-third of Americans who experience chronic pain, an independent panel of medical experts has concluded.

The panel, convened by the National Institutes of Health, released its findings in a report published Jan. 12.

Prescription painkillers have been linked to addiction and death. More than two-thirds of the 22,767 drug-related overdoses in 2013 involved opioids, according to the Centers for Disease Control and Prevention.

The panel found that some patients experiencing pain are often denied effective comprehensive treatments, while other patients are inappropriately prescribed medications. In addition to studying opioid effectiveness, more research is needed on management and risk mitigation strategies, the panel said.

In the meantime, the panel recommends health care providers follow guidelines issued by professional societies, and for those guidelines to be continually updated as new research is conducted.

http://www.safetyandhealthmagazine.com/articles/11705-nih-panel-on-opioid-use-calls-for-individualized-treatment-for-americans-in-pain