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By Lisa Lake-Salmon
Lisa Lake-Salmon

Denials are difficult to identify and time consuming to appeal. With healthcare reform and new Medicare mandates coming at a dizzying rate, running an O&P practice gets more complicated every year. This month's column addresses your questions regarding the maximum benefit amount for a prosthesis, PECOS implementation, direct deposits of Medicare reimbursements, and more.

Q: I received a denial from United Healthcare (UHC) stating a patient's plan had met the maximum benefit for the prosthesis I provided, and I was reimbursed $1,400 for a $60,000 transtibial prosthetic device. How is this possible? I obtained prior authorization and verified the patient's benefits. I am a relatively new provider in the State of Colorado and cannot afford to not be reimbursed for the device I provided the patient. Please help!

A: According to Colorado House Bill 00-1478 section 1, 10-16-104, mandatory coverage provisions (14)(a), any health-benefit plan that is not a supplemental limited-benefit policy must provide coverage of benefits for prosthetic devices that equal those benefits provided for under federal laws for health insurance for the aged and disabled. In other words, in the State of Colorado, there is no benefit maximum for a prosthetic patient. Go to www.state.co.us/gov_dir/leg_dir/olls/sl2000/sl_330.htm to view the bill in its entirety.

Q: I know you have mentioned in previous articles information regarding the PECOS system and when it will go into effect. Is there a list I can access to look up this information, or do I need to call each one of our referring physicians directly?

A: Effective January 3, 2011, if the ordering physician does not have updated enrollment information in the Provider Enrollment, Chain, and Ownership System (PECOS), your claim will be rejected. The Centers for Medicare & Medicaid Services (CMS) has made available a file that contains all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain a national provider identifier or NPI). This file is downloadable from the Medicare provider/supplier enrollment website at cms.gov/MedicareProviderSupEnroll.

After accessing the link, click on "Ordering/Referring Report" on the left-hand side. (Editor's note: You can also check physicians' PECOS enrollment status at www.oandp.com by clicking on the PECOS Search button, located at the top left-hand side of the page.)

Q: I am a new provider in Louisiana, and I was told I can have Medicare reimbursements direct deposited into my bank account—is this true? How do I sign up for this?

A: To receive electronic funds into your bank directly from Medicare, you need to go to the following web address: www.cignagovernmentservices.com/jc/forms/pdf/JC_EFT_form.pdf. You will need to fill out the electronic funds transfer (EFT) authorization agreement. The instructions are pretty straightforward.

Q: A colleague of mine states that all L-Codes require a K-level modifier when billing a prosthetic claim to Medicare. I say that not all L-Codes require the K-level modifier. Which one of us is right? We have bet a round of golf on this one.

A: I hope you are ready to tee up! Regarding claims billed for knees, feet, and ankles (L-5610-L-5616, L-5710-L-5780, L-5810-L-5840, L-5848, L-5856-L-5858, L-5930, L-5970-L-5987), the component must be submitted with modifiers K0-K4 indicating the expected patient functional level.

Lisa Lake-Salmon is the 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