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By Lisa Lake-Salmon
Lisa Lake-Salmon

Denials are difficult to identify and time-consuming to appeal. Because we understand that running an O&P practice gets more complicated each year, 'Got FAQs?' is here to help you with your toughest billing questions. This month's column covers your questions about the provision of services to prison inmates, denials and justification for the CROW Boot, re-determination requests, and more.

Q: I am a new provider in Maryland and recently received a contract to provide services to prison inmates. Where can I find information on the correct Medicare billing process for this? I would like to get reimbursed the first time for the items I provide.

A: Medicare recently issued a related change request regarding services furnished to Medicare beneficiaries who are in state or local custody. The MLN Matters article about Change Request 6544 can be viewed in its entirety at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6544.pdf. There are two other articles relating to Medicare beneficiaries who are in custody: These may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1812CP.pdf and www.cms.hhs.gov/Transmittals/downloads/R110BP.pdf

Q: We have recently received denials regarding the coding and justification of a CROW Boot. Can you clarify the L-Codes that we should use and the medical justification for the device according to Medicare? We cannot afford to provide services for which we will not get reimbursed.

A: The Charcot Restraint Orthotic Walker, also known as the CROW Boot, was developed for patients with severe deformity of the foot and ankle due to a sensory neuropathic arthropathy, which is most commonly caused by diabetes. The following codes are used to bill for a CROW Boot: L-1960, L-2232, L-2275, L-2340, L-2820, and L-3010. The base code and additions are considered medically necessary for ambulatory patients with weakness or deformity of the foot and ankle, require stabilization for medical reasons, and have the potential to benefit functionally. You may view Medicare's policy regarding ankle-foot orthoses and knee-ankle-foot orthoses at www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11517&lcd_version=46&show=all

Q: We received denials from Medicare in June 2009. We received the additional documentation from the referring physician in December 2009 and resubmitted the claim. We were told that we were past the timely filing deadline. We were also told that we did not use the correct form to request the appeal. I thought we had over a year to submit our Medicare claims. We are located in Region C.

A: Re-determination requests must be filed with CIGNA Government Services (CGS) within 120 days of the date of the initial Medicare denial. In the future, fax your information to Medicare at 615.782.4630 within 120 days of receiving the denial. Depending on the denial you receive, you will either need a Reopening Request Form or a Re-determination Request Form. You may view the forms at www.cignagovernmentservices.com/jc/forms/pdf/JC_reopenings_form.pdf and www.cignagovernmentservices.com/jc/forms/pdf/JC_redetermination_form.pdf

Q: If I bill for an L-1843 knee orthosis, which additions codes can I bill for separately? What are the diagnosis codes a patient needs to have in order for this device to be considered medically necessary?

A: The addition codes eligible for separate payment when billing the L-1843 as your base code are L-2385, L-2395, and L-2397. According to Medicare policy, a knee orthosis with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L-1843) is covered for a patient who is ambulatory and has knee instability due to a condition specified in one of the following diagnoses: 340, 342.90, 343.9, 344.1, 355.0, and 355.2.

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. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact or visit www.acc-q-data.com