Billing and Collections Q&A

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By Lisa Lake-Salmon

Running an O&P practice and keeping billing on track is complex and time-consuming. When you have a billing-related question, "Got FAQs" has the answer. This month's column addresses your questions about what addition codes are appropriate with knee orthoses for patients who weigh more than 300 pounds and documentation requirements when billing for L-5859.

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Q: I work for an O&P provider in Texas. We have gotten referrals from a bariatric group for custom-fabricated knee orthoses such as L-1844 (knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated); L-1846 (knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated); and L-1840 (knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated). Are there any addition codes or modifiers that I would need to use if the patient weighs more than 300 pounds? Some of these patients are extremely overweight, and I was told to ask if we would use certain L-Codes for these patients.

A: There are specific diagnosis codes to state that the patient is considered obese, 278.00 to 278.03; however, there are not specific modifiers to indicate this. If one of the diagnosis codes indicating obesity is documented in the patient's file, or if there is documentation that the patient's weight is in excess of 300 pounds, there are two codes that are covered for beneficiaries as additions that can be billed and reimbursed separately when billing for custom knee orthoses. Those codes are L-2385 (addition to lower extremity, straight knee joint, heavy duty, each joint) and L-2395 (addition to lower extremity, offset knee joint, heavy duty, each joint). To view complete information, visit www.oandp.com/link/245

Q: We currently have two patients who are going to receive lower-limb prostheses that include L-5859 (addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)). The codes the practitioner provided are L-5856 (addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type); L-5828 (addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control); L-5845 (addition, endoskeletal, knee-shin system, stance flexion feature, adjustable); L-5848 (addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability); and L-5859. What are the requirements for L-5859. I am not familiar with billing for these types of devices, and I want to make sure my claim and documentation are complete.

A: L-5859 is only covered when the beneficiary meets all of the following criteria:

  1. Patient has a microprocessor (swing- and stance-phase type (L-5856)) controlled (electronic) knee.
  2. Patient has been classified with a K3 or above functional level.
  3. Patient weighs more than 110 lb. and less than 275 lb.
  4. Patient has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3 level function with the use of a microprocessor-controlled knee alone.
  5. Patient is able to make use of a product that requires daily charging.
  6. Patient is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.

There must be information in the patient's file that clearly documents the expected beneficiary's functional level. In addition, there must be documentation from the beneficiary's physician about his or her history and current condition that supports the functional level designation. For L-5859, the medical records should describe the nature and extent of the comorbidity of the spine or the sound limb that is limiting this beneficiary to a household ambulator and clearly document how this feature will enable the beneficiary to function as a community ambulator. For complete lower-limb prosthetics coverage, visit www.oandp.com/link/246

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