Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing for O&P devices and care is complicated. Count on "Got FAQs?" to help ensure you are using the most current information when preparing your claims. This month's column answers your questions about coding for cosmetic additions, toe fillers or inserts for patients with diabetes, and modifiers for L-3923.

Q: We recently started billing for the Ottobock Dynamic Arm® and are not familiar with the proper coding for cosmetic materials such as coloring, veins, and hair. Other providers have advised us to use L-7499 (upper-extremity prosthesis, not otherwise specified) for these additions. However, the practitioner I work for recently took a coding course, and he was told this is incorrect. Can you clarify what L-Code we should use for these additions?

A: On May 18, the Centers for Medicare & Medicaid Services (CMS) released a statement to clarify billing for these additions. L-6895 (addition to upper-extremity prosthesis, glove for terminal device, and any material, custom fabricated) is the appropriate code to bill for a prosthetic cosmetic glove including matching color, hair, skin, and wrinkles. Suppliers should not bill using L-7499 for the cost of the additional cosmetic features. The long narrative description for L-6895 indicates "any material," and therefore includes all of these cosmetic features. For more information, visit www.oandp.com/link/160

Q: My colleague and I are debating proper coding for toe fillers and inserts for patients with diabetes. I bill using A-5512 (multiple density insert, custom molded) or A-5513 (multiple density insert, direct formed). My colleague believes these codes are incorrect. We are located in Kentucky.

A: There are two ways that providers can bill for inserts for a patient with diabetes who has missing digit(s) or a forefoot. For beneficiaries with diabetes who do not require the rigidity and support afforded by L-5000 (partial foot, shoe insert with longitudinal arch, toe filler)-for example, beneficiaries who are missing digits excluding the hallux-suppliers must bill code A-5513 for an insert appropriately custom-fabricated to accommodate the missing digit(s). Codes L-5000 or A-5512 may not be billed in addition to code A-5513. For beneficiaries who are missing the hallux or a forefoot and require rigidity and support for effective gait, suppliers must bill L-5000 for an insert appropriately custom fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A-5512 or A-5513 may not be billed in addition to code L-5000. For more information on this coding clarification, visit www.oandp.com/link/161

Q: I billed Medicare for code L-3923 (hand finger orthosis, without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment) with KX and RT modifiers. My claim keeps getting rejected as incorrect coding, and I am not sure how to bill for this item and get it paid.

A: L-3923 includes both elastic and non-elastic items. Effective for claims with dates of service on or after July 1, 2010, if an L-3923 orthosis has a rigid plastic or metal component, the supplier must add the CG modifier (policy criteria applied) to the code. Claims for L-3923 billed without a CG modifier will be rejected as incorrect. For more information, visit www.oandp.com/link/162

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