Billing and Collections Q&A

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By Lisa Lake-Salmon

Denials are difficult to identify and time-consuming to appeal. Count on "Got FAQs?" to help you sort through the complexities associated with O&P billing. This month's column addresses your questions about how to differentiate between the new knee orthosis split codes as off the shelf or custom fitted, and documentation requirements for diabetic shoes.

Q: I read that there are two new codes for off-the-shelf (OTS) knee orthoses (KOs), and these would be different from the codes you would use if the brace is custom made. Can you clarify which codes are appropriate under what circumstances? I have researched what Medicare considers custom fitted, and I find the wording confusing.

A: If you provide a patient with a KO, single upright, thigh and calf, with adjustable flexion and extension joint medial-lateral and rotation control, or with a KO, double upright, thigh and calf, with adjustable flexion and extension joint, mediallateral and rotation control, and the brace only requires minimal self-adjustment for appropriate use by the patient, use code K-0901 or K-0902, respectively. If either of these KOs require the services of a certified orthotist (a practitioner who is certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) or by the Board of Certification/Accreditation (BOC), or an individual who has specialized training) in order to trim, bend, mold, assemble, or customize to fit a specific patient, then use code L-1843 (single upright) or L-1845 (double upright). For more information, visit www.oandp.com/link/288

Q: I work for an orthotic provider in Florida. We recently received denials on claims for diabetic shoes due to incomplete documentation. Of course we sent in everything we had in the patients' files. Can you tell me what exactly needs to be in the file when we dispense this item?

A: A supplier of diabetic shoes must obtain a signed statement from the physician who is managing the beneficiary's diabetes-related condition specifying that the beneficiary has diabetes mellitus, has one of the conditions in the related Policy Article, is being treated under a comprehensive plan of care for his or her diabetes, and needs diabetic shoes. The certifying physician must be a medical doctor (MD) or doctor of osteopathic medicine (DO), and may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist. It is recommended that your patient file include the Statement of Certifying Physician for Therapeutic Shoes form. This statement must be completed, signed, and dated by the certifying physician. A new certification statement is required for a shoe, insert, or modification that is provided more than one year from the most recent certification statement on file.

However, the certification statement by itself does not meet the documentation requirements for the patient's medical record. The supplier must complete an in-person evaluation of the beneficiary at the time the item to be dispensed is selected. The evaluation must include an examination of the beneficiary's feet with a description of the abnormalities that will need to be accommodated by the shoes, inserts, or modifications. If you are going to provide shoes, take measurements of the beneficiary's feet. If you are going to provide A-5501 (Diabetic custom molded shoe) and A-5513 (Multi den insert custom mold), take impressions, make casts, or obtain CAD/CAM images of the beneficiary's feet that will be used to create the positive models.

The supplier must again conduct an in-person evaluation of the beneficiary at the time of delivery. The evaluation must be conducted with the beneficiary wearing the shoes and inserts, and the supplier must document that the shoes, inserts, or modifications fit properly. For a documentation checklist, visit www.oandp.com/link/289. To read the related Policy Article, visit www.oandp.com/link/290

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