December 2017 Issue
Billing for O&P devices seems to get more complicated by the day. Count on Got FAQs? to help answer your toughest questions. This month's column addresses billing for a custom brace that could not be delivered, and modifier codes to use with custom-fabricated knee orthoses.
Q: I am a provider in Colorado. I recently made a custom brace for a Medicare beneficiary. When we contacted the patient to pick up his brace, we were informed that he had passed away. I am sure I am unable to bill for this device because the finished product was never delivered to the patient, but is there anything a provider can do? My next question: Two patients I treated this week each previously received an L-1833 and a L-1843 knee orthosis, so can I provide another brace? How long does a patient need to have his or her brace before receiving a new one?
A: As stated in the Medicare Supplier Manual, Chapter 5, page 3, Artificial Limbs, Braces, and Other Custom-Made Items Ordered but Not Furnished (https://www.cgsmedicare.com/jc/pubs/pdf/chpt5.pdf): "If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary's condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made either on an assigned or unassigned claim basis, based on your expenses." If this happens, the date of service is either the date the beneficiary died, the date that you learned of the cancellation of the item, or the date that you learned that the item was no longer reasonable and necessary or appropriate for the beneficiary's condition. The allowed amount is based on the services furnished and materials used, up to the date you learned of the beneficiary's death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Medicare Administrative Contractor (DME MAC) determines the services performed and the allowable amount appropriate to the situation, taking into account any salvage value of the device. Whether a supplier has lived up to its agreement, of course, depends on the facts in the individual case.
The provider's medical records should always reflect all the detailed information that supports your claim. The reasonable useful lifetime for L-1833 is two years and L-1843 is three years. Replacement during the "reasonable useful lifetime," is covered if the item is lost or irreparably damaged. The reasonable useful lifetime of a custom-fabricated orthosis is three years. For a chart provided by Medicare that reflects the reasonable useful lifetime of prefabricated knee orthoses, see pages 38 and 39 at http://bit.ly/2zLmov.
Q: I recently started working for a provider in California and this is the first time I am billing for knee braces. I have always worked for surgeons, so the coding is different. I submitted two claims for custom-fabricated knee orthoses and Medicare denied the claim because I did not have the appropriate modifier and I billed incorrect addition codes for the brace. I have included the claims I submitted for L-1840 and L-1844. Would you review them and advise how to do it properly?
A: Your claims must include the KX modifier (Requirements specified in the medical policy have been met) and RT (right) or LT (left) must be added to the base code and all addition codes. Each brace has specific addition codes that can be billed and paid separately. For L-1840 the addition codes are L-2385, L-2390, L-2395, L-2397, L-2405, L-2415, L-2425, L-2430, L-2492, L-2755, L-2785, and L-2795. The L-1844 addition codes are L-2385, L-2390, L-2395, L-2397, L-2405, L-2492, L-2755, and L-2785. For a list of all codes and modifiers and a list of all addition codes eligible for separate payment and the base code they are billed with, visit http://bit.ly/GotFAQsDocDec17. To review the documentation checklist for knee orthoses to ensure you have all required documentation, visit http://bit.ly/GotFAQsDec17.
Lisa Lake is an independent medical consultant with over 24 years of experience in the O&P industry, increasing providers' revenue by product recommendation, product and billing knowledge, and contract access assistance. She is a nationally recognized speaker on billing reimbursement and government compliancy. Lake can be contacted at firstname.lastname@example.org.