Got FAQs? - Billing and Collections Q&A

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By Lisa Lake-Salmon

Running an O&P practice is complicated. When you have a question, count on "Got FAQs?" to get you back on track. This month's column tackles your questions about quality guidelines for the provision of diabetic shoes, L-Code resources, claim denials, and more.

Q: I read in a medical magazine that Medicare had changed some guidelines for providing diabetic shoes. Have you heard anything about this? Do you know where I can find out more information on these guidelines?

A: On October 24, 2008, CMS issued the final revision to its "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Quality Standards." The revised standards provide more detailed and specific guidelines for providing diabetic shoes. I recommend that all providers read Medicare's revised quality standards to ensure they are up to date. The 19-page document can be found at www.cms.hhs.gov/medicareprovidersupenroll/downloads/dmeposaccreditationstandards.pdf

Q: I recently opened a P&O practice in California and am not that familiar with all the current L-Codes. Is there a website or free listing I can use to verify if my coding is correct?

A: There are two websites that our office uses frequently to verify Healthcare Common Procedure Coding System (HCPCS) codes. To search by individual codes, visit www.dmepdac.com/dmecsapp/do/search . For a complete listing of all current HCPCS codes, visit www.noridianmedicare.com/dme/news/manual/chapter16.html#

Q: I have always been a non-participating provider with Medicare, and my enrollment period is coming up. What are the benefits of being a participating provider?

A: When you are a participating provider, you must always accept assignment of claims for all services you furnish to Medicare beneficiaries. CMS lists the following benefits of participation: Becuase the claims are always assigned, Medicare payments are issued directly to the DMEPOS supplier. Claim information is forwarded to Medigap insurers. Ultimately, only you can decide which is more beneficial to your practice. For more information, see www.cms.hhs.gov/medicareprovidersupenroll/downloads/durablemedicalequipment.pdf

Q: I submitted a claim to Medicare using L-1846 as my base code, along with L-2405, L-2820, L-2770, and L-2796. Medicare denied payment. When we called Medicare, it said we needed the correct modifier. Can you help with this? We have billed in the past with the LT or RT modifier and have been paid.

A: Effective July 1, 2008, the KX modifier should be appended to both the base knee-orthosis code and any addition code(s) only if all the coverage criteria in the "Indications and Limitations of Coverage and/or Medical Necessity" section of the Knee Orthoses Local Coverage Determination (LCD) have been met, and documentation is retained in the supplier's files. If you left off the KX modifier (specific required documentation on file) and your claim denied for CO-50 (not medically necessary), you may contact the claims reopenings department, and it will add the KX modifier to your claim. The department will resubmit your claim at that time, and it should be processed within 14 days. You did not state your date of service, so please note that L-2796 is no longer a valid code.

Lisa Lake-Salmon is the executive vice president of Acc-Q-Data, which provides billing, collections, and practice-management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. For more information, contact lisa@opedge.com