Got FAQs: Prosthetic Medicare audits and billing for shoe inserts for patients who have undergone toe amputation

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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 prosthetic Medicare audits and billing for shoe inserts for patients who have undergone toe amputation(s).

Q: I am a prosthetic provider in Region B and have received numerous audits on my Medicare prosthetic claims. I heard this is going on throughout our industry. I read somewhere that Medicare issued a publication regarding why it is auditing all of these claims and what I need to do. Can you tell me where I can find this information?

A: The Office of Inspector General (OIG) reported that Medicare inappropriately paid $43 million in claims for lower-limb prostheses in 2009; these payments could have been prevented by using claims processing edits. These payments were for claims that did not meet the requirements specified in the local coverage determination (LCD). The $43 million is based solely on an analysis of claims data and does not include payments that a medical record review may find to be unreasonable or unnecessary. Most of these payments were made to suppliers who incorrectly billed for prostheses for both the right and left limbs using two claims, rather than one. Billing in this manner allows these suppliers to appear to be billing for only one limb when in fact they are billing for both limbs. In other cases, the claims did not include any information about the beneficiaries' potential functional level when it was required, or the claims were for prostheses that were not medically necessary given the beneficiaries' potential functional level. To read the report, visit www.oandp.com/link/187

Q: I just started billing for an O&P practice in West Virginia. Though I have done billing in the past for physicians, I find it more complicated to code correctly for some of the items the O&P practice provides to patients. I have received denials and do not know where else to turn for help. I am billing for shoe inserts for a patient who has undergone toe amputations. I was told to use either A-5512 (for diabetics only, multiple density insert, direct formed) or A-5513 (for diabetics only, multiple density insert, custom molded), and some of my claims get paid while others are denied.

A: You did not specify if the inserts you are billing for are for patients with or without diabetes. Shoe inserts for beneficiaries with missing toes or partial foot amputations who do not have diabetes would be billed with code L-5000 (partial foot, shoe insert with longitudinal arch, toe filler). L-5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries who are missing digits, particularly the hallux or the forefoot, L-5000 inserts are designed to provide standing balance and toe off support for improved gait. The biomechanical control required of L-5000 differs from the foot-protective function provided by inserts used as part of diabetes management. Codes A-5512 and A-5513 describe inserts used with therapeutic shoes provided to persons with diabetes and must not be billed for beneficiaries who do not have a diabetes diagnosis. The Centers for Medicare & Medicaid Services (CMS) Region C contractor, CGS, published this information in a press release on June 7, 2012. To read the complete release, visit www.oandp.com/link/188

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