TriCenturion, the Jurisdiction B DME Program Safeguard Contractor, said it has has identified a number of suppliers who are marketing what are often described as "arthritis kits." According to a June 5 notice, the PSC said advertisements for these kits — which can include multiple upper limb, lower limb and spinal "orthotics" and/or heat lamps — "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 aupplement plan)."
But the PSC pointed to several problems with the kits in cases it has investigated: Many of the items are billed using incorrect HCPCS codes; many are statutorily noncovered by Medicare; and "in almost all cases," documentation does not support the medical necessity for the items.
"A simple diagnosis of arthritis or other general statement is not sufficient," the PSC said. "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."