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Dynamic Chiropractic – August 12, 2010, Vol. 28, Issue 17

Support Your Billing Claims for Bracing Materials

By K. Jeffrey Miller, DC, MBA

Braces and supports are frequently a part of chiropractic treatment plans. They can help after an acute injury, stabilize a chronic condition, and can also be considered safety devices. Most chiropractors have a supply of braces and supports on hand that reflect their style of practice.

When necessary, they dispense them accordingly, typically by putting the brace on the patient for the first time or by providing the brace with verbal instructions. For years, these methods sufficed. However, in today's world of managed care, medical necessity, evidence-based practice and increased record-keeping standards, these methods are no longer adequate.

There are several necessary steps required to meet current demands for including a brace or support in a patient's plan of care. Braces and supports must be written into the plan, and the brace or support must be accompanied by documentation that includes classification of injury/illness; clinical reasoning; time frame for use; description of the brace or support; and insurance verification and billing. Without the above, the chances of proving medical necessity are low. Inclusion in the plan of care also adds emphasis to the importance of the brace or support as part of needed care.

Injury Classification

Orders for braces and supports should differentiate which category an injury falls into for documentation purposes. The devices can be applied for work-related, personal-injury, home and recreational traumas and conditions. This helps clarify to an insurance carrier who is responsible for covering the brace or support.

A workers' compensation carrier will not cover a brace needed for a personal-injury case, and a personal-insurance company will not cover a brace or support needed for workers' comp. While this seems obvious, it is not unusual for patients being seen for a specific condition to ask for another brace or support they want that is unrelated to their current condition, since "the insurance is already paying." This is not true. Be sure to only ask for insurance reimbursement for the braces or supports relevant to the individual patient's specific needs.

Clinical Reasoning

Clinical reasoning is a key to medical necessity and evidence-based care. The doctor must show justification for applying a brace or support. Reasons can include: postural support, relief of spasm, pain relief, promotion of rest, partial immobilization, total immobilization, proprioceptive awareness, decreasing the risk of re-injury, to reduce joint-muscle loading, etc.

Time Frame for Use

Most braces and supports are for temporary use. A few types (such as orthotics) are of a more permanent nature. In either case, the time period for use must be defined for the patient and for any involved third party. Times and situations should be defined. Some examples of appropriate terms to use for time include temporary, long term, nocturnal, constant, and as needed. Situations can be listed as occupational, household, driving, lawn and garden, lifting, recreational, etc. Time and situations could both be described by the phrase "as needed."

An important factor here is the crossover use of braces and supports for home, occupation and recreational uses. If an employee is placed in a back brace for a work-related injury, use should carry over to home and occupational uses. In addition, all work restrictions must also carry over into other aspects of life. It is a bad idea for an employee placed in a brace and on light duty to be seen playing softball on the weekend without the brace.

Description of the Support Device

Braces and supports applied for home and recreational injuries may have to be issued with a note or letter to an employer in order for the device to be used on the job. The doctor should provide a description of the brace or support issued. Detail here is vital, as reimbursement is often associated with the material makeup of the device. Be as specific as possible.

Insurance Particulars

Braces and supports are often covered by insurance carriers under a separate set of rules. This makes it necessary to verify their coverage separately in most cases. The distinct rules are for durable medical equipment (DME). The verifier should ask about DME specifically and for that insurer's definition of DME. In many cases, "durable" means "rigid." The brace must have plaster, plastic or metal in its makeup. Custom-fitted braces or supports can also pass the DME rules, as custom-fitted also means custom-made.

Finally, when a brace or support is billed to an insurance carrier, it is best to file the items on a separate claim form and provide the documentation described above. Most claims that require accompanying documentation are best processed separately and at a slower rate. This prevents the consideration of the brace or support from slowing down the reimbursement of other services if they are also listed on the same claim. Claims are processed at the rate of the most difficult item to process.

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