Got FAQs?

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By Lisa Lake-Salmon
Lisa Lake-Salmon

Whether you are new to O&P billing or have years of experience, denials can be frustrating to handle and difficult to appeal. Count on "Got FAQs?" to provide you with the information you need to save time and frustration. This month's column addresses your questions about organizing patient paperwork, upgrading DMEPOS items, and billing requirements for pneumatic compression devices.


Q: What would be the best or correct way to organize information in patient file folders? We use two-prong file folders. Do all the papers have to be hole-punched and put on the metal prongs? For example, if a patient received a knee brace one month and a wrist splint the next, can the paperwork for the knee brace (medical necessity form, delivery slip, patient wear info, copy of the HCFA-1500 form filed to the insurance company, etc.) all be stapled together, and the same with the wrist splint paperwork?

A: As referenced in the Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, §5.7, for any durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, etc. It does not state that the patient's file be maintained in any particular order. You may view this information at www.cms.gov/manuals/downloads/pim83c05.pdf

Q: CMS Policy Article A37065, effective July 1, 2010, states, "Deluxe features of diabetic shoes (A-5508) will be denied as non covered." If a diabetic patient gets a Medicare-allowed boot that costs the supplier almost as much or more than the Medicare therapeutic footwear allowance, can I charge the Medicare patient the difference and just file an Advance Beneficiary Notice (ABN)?

A: When you furnish an upgraded DMEPOS item and expect Medicare to reduce the payment level based on a medical necessity partial denial of coverage for additional expenses attributable to the upgrade, you must have the beneficiary sign an ABN, which holds the beneficiary liable for the additional expense. Indicate modifier GA on the Medicare claim with the appropriate Healthcare Common Procedure Coding System (HCPCS) code. To view a complete list of modifiers, visit www.cignagovernmentservices.com/jc/pubs/pdf/Chpt16.pdf. You will need ABN form CMS-R-131, which can be found at www.cms.gov/BNI/02_ABN.asp

Q: I am billing for a transtibial prosthesis (L-5500). Where can I find a list of additions or components I can bill with this base code?

A: According to the local coverage determination (LCD) for lower-limb prostheses, "When an initial below knee prosthesis (L-5500)...is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L-5629, L-5638, L-5639, L-5646, L-5647, L-5704, L-5785, L-5962, and L-5980 which will be denied as not medically necessary." To view the full text of this LCD, visit www.cms.gov/mcd/viewlcd.asp?lcd_id=11442&lcd_version=40&show=all

Q: I am an O&P provider in rural Louisiana. Some of my referring physicians are requesting that I provide pneumatic compression devices to their patients. I am not familiar with their billing requirements. Can you tell me where I can find information on these devices?

A: For coverage and medical policy information, refer to the local coverage determination (LCD) for pneumatic compression devices at www.cms.gov/mcd/viewlcd.asp?lcd_id=5017&lcd_version=30&show=all

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