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 the Medicare Program Integrity Manual, new and discontinued L-Codes, and how Round 2 of the Competitive Bidding Program will affect orthotists.

Q: Can you please send me a link to the Medicare Program Integrity Manual I have spent a day looking for it, but have not been successful. Can you let me know what this section is in regard to?

A: The section you are looking for is actually 3.2.1 - Setting Priorities and Targeting Reviews (Rev. 399, Issued: 11-04-11, Effective: 12-05-11, Implementation: 12-05-11). As written therein: "This section applies to MACs [Medicare Administrative Contractors] and Recovery Auditors, as indicated. Recovery Auditors perform targeted reviews consistent with their statements of work (SOWs). The MACs have the authority to review any claim at any time, however, the claims volume of the Medicare Program doesn't allow for review of every claim. The MACs shall target their efforts at error prevention to those services and items that pose the greatest financial risk to the Medicare program and that represent the best investment of resources. This requires establishing a priority setting process to assure MR [medical review] focuses on areas with the greatest potential for improper payment." To view the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, visit

Q: For the last ten years, I have looked forward to your column on the new and discontinued codes for the new year. Can you please advise me of any new or discontinued L-Codes for 2015? I need to update my paperwork and computer systems. I appreciate your help and enjoy reading your column.

A: Effective January 1, the added L-Codes are L-3981 (upper extremity fracture orthotics, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments); L-6026 (transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)); and L-7259 (electronic wrist rotator, any type). The deleted codes are L-7260 and L-7261; they have been crosswalked to L-7259.

Q: I am a Region A provider and have been concerned about all of the Medicare program changes. I recently saw an article about competitive bidding and how it affects orthotists. Can you advise me about the products that are included and how it will affect my business?

A: On Thursday, December 11, 2014, the Centers for Medicare & Medicaid Services (CMS) announced the bidding timeline for the Round 2 Recompete of the Competitive Bidding Program and the National Mail-Order Recompete of the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Competitive Bidding Program. Off-the-shelf (OTS) orthoses were not included as a product category in this round of competitive bidding. An article about this can be found on the American Orthotic & Prosthetic Association website; to view it, visit

The products included are: enteral nutrients, equipment and supplies; general home (includes hospital beds, group 1 and 2 support surfaces, commode chairs, patient lifts, and seat lifts); nebulizers and related supplies; negative pressure wound therapy pumps; respiratory equipment (includes oxygen, oxygen equipment, and supplies; continuous positive airway pressure devices and respiratory assist devices); standard mobility equipment and related accessories (includes walkers, standard power and manual wheelchairs, and scooters); and transcutaneous electrical nerve stimulation devices and supplies. To read the CMS fact sheet, visit

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