Hidden in Plain Sight – Upcoding

The very first charge on my doctor’s bill confounded me. The abbreviated description reads

Tlso, anterior-posterior-lateral co

What the hell is that supposed to mean? Whatever it was, it had to be important. The surgeon’s office had charged $2,500 for it—$2,730 with modifications.

Okay, I know that anterior is front, posterior is rear, and lateral is side. But with the small size of the print, I couldn’t tell whether the second character of the first term was a 1 (numeral one), an I (upper case), or an L (lower case). I obtained a medical abbreviations app for my iPhone and tried all three combinations. TLSO turned out to be the winner, meaning thoracolumbsacral orthosis, a mouthful of Latin that really just means back brace for the lower torso.

In the hospital, on the second day of my recovery, I was given a grey back brace and told that, for the next twelve weeks, I was not to get out of bed without first strapping on that brace. The contraption was quite comical. I wish I’d gotten a picture of the brace in its original form, which was clearly intended for someone about forty or fifty pounds heavier than me. It looked like the under-frame for a Santa suit. Of course, the appearance is unimportant, but as I explained to the surgeon the next time I saw him, the brace, with the straps tightened down, only touched my body at the armpits and hips. I was pretty sure it wasn’t going to stabilize my torso, which is what everyone said it was supposed to do.

The surgeon insured me fitting was no problem, that he could have the brace adjusted and would send someone to do so. The fitter arrived the same day. He measured my waist (at the navel) and my chest and took the brace with him. He returned the brace the next day.  It had been cut down and reformed (probably with a hot air gun) to fit my body type. One replaced pad made the whole unit a perfect fit. I did photograph this one.

This was worth $2,700 dollars?

A little more research told me that the code—L0486—was a HCPCS (Healthcare Common Procedure Coding System) code. Checking the online HCPCS lookup, I found that L0486 means:

TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER, MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTIC, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE PLANES, INCLUDES A CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATED

Easy to see why they don’t want to put all of that on a bill—and it’s just one line item. As for what it all means, well we’ve already covered TLSO. Most of the rest of the paragraph just describes what the brace is made of, where it fits on the body, and how it works. The last words of the description, after the word includes, were the most disturbing to me, especially those last two words: custom fabricated.

Custom fabricated? Okay, it was fitted. Still, that’s not the same thing as custom fabricating a brace from a CAD-CAM model (where photos are turned into a 3D computer graphic) or from a plaster cast. My brace was initially an ill-fitting off-the-shelf job.

Once I obtained a copy of the HCPCS manual, after a little browsing (hard to accomplish in the online lookup site), I found the description that matched my brace completely, on the page just before L0486, under code number L0460:

TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

Note that, in this case, the key words at the end—prefabricated, includes fitting and adjustment—describe my back brace, exactly.

The doctor’s office requested payment of $2,730 for the brace plus the extra pad and a cotton liner. All told, the insurance company allowed $1,095 and change for the brace plus modifications, of which I had to pay $350 out-of-pocket. Good thing I was insured, eh? An uninsured patient would have had to cough up the entire $2,730. At $350, after monthly insurance payments and my annual deductible, there’s really only one possible conclusion:

I wuz robbed!

I could have manufactured that thing for under $200.

But wait, it gets worse. The Medicare allowance for an L0486 is roughly $1,600. Their allowance for an L0460—the brace I actually got—is half that, which would have included the extra pad at no additional charge. I wonder what my out-of-pocket cost would have been if this had been correctly coded. Don’t get me wrong, the brace worked fine and was fitted properly, but did it have to cost that much?

Of course not.