Billing and Collections Q&A

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By Lisa Lake-Salmon
Lisa Lake-Salmon

Billing for O&P devices and care is complicated. Count on "Got FAQs?" to help ensure you have the most current information when preparing your claims. This month's column addresses your questions about Medicare documentation, billing for custom orthotic device orders that are canceled after fabrication, and L-Code descriptions.

Q: We are an O&P facility in Georgia that recently opened, and we just received our first referral for a transtibial patient. I want to make sure my documentation is complete and accurate should we need to provide it to Medicare. Do you have any suggestions for documentation and how it should be recorded in the patient's file?

A: You want to provide clear, concise, and comprehensive information that is specific to the policy so that there is no doubt that the services are needed and, more importantly, covered under the policy. Reference policy criteria in your letter of medical necessity. Your supporting documentation should state how the service or component will benefit the patient's overall medical condition. For example, if the patient has a history of contralateral knee compromise and requires the stability features of a microprocessor knee, you should name all of the patient's conditions. Of course, your explanation should go into much more detail relative to the possible benefits and ramifications of either providing or not providing the proposed service or component. State your rationale for choosing this course of treatment. Show that you considered alternatives to a microprocessor knee and then point out how the functionality of a non-microprocessor knee falls short of meeting the patient's functional requirements. Contrast this with the functionality of a microprocessor knee and relate this to the patient's functional needs to show that a microprocessor knee is the least costly and most functional alternative. Any hint that another component or service would be more comfortable or convenient to the patient could garner an immediate denial. Avoid words in your documentation that allude to this, such as easier, less irritating, multiple adjustments, etc.

Q: I have a patient for whom I made a custom-molded bivalve healing boot. During fabrication, the patient went into the hospital for other reasons and by the time he was released, the physician determined he no longer needed the orthosis. How do I bill for this? I am not comfortable billing a patient's claim for something the patient will not wear. Do I bill for parts and labor instead of the L-Code?

A: According to Medicare Quality Standards, if a custommade item was ordered but not furnished to a beneficiary because the individual died, the order was canceled by the beneficiary, or the beneficiary's condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier's expenses. In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation. The allowed amount is based on the services furnished and materials used up to the date the supplier learned of the beneficiary's death or of the cancellation of the order. Your Durable Medical Equipment Regional Carrier (DMERC) determines the services performed and the allowable amount appropriate for each particular situation. It takes into account any salvage value of the device to the supplier. Visit www.oandp.com/link/101 for additional information.

Q: Where can I find a list of L-Code descriptions? I am located in Region D and the Noridian Medicare page we were using has moved.

A: Noridian Medicare has changed its website. A complete list of all active L-Codes and their descriptions can now be found at the following URL: www.oandp.com/link/102

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