Billing and Collections Q&A - December 2018
December 2018 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 includes information on modifier codes for knee orthoses and billing for custom liners.
Q: I am an orthotist in Texas and recently opened my own practice. I am doing the billing myself and just received my Medicare Provider Transaction Access Number. I have seen several patients who will either need a knee immobilizer without joints or a knee orthosis with adjustable knee joints. If a patient already received one of these braces, how long do I have to wait before providing another one according to Medicare? If I add some components or features to the brace, do I bill these separately or are they part of the orthosis? Which codes would I use for the suspension? Are there specific modifiers I need to use when billing claims to Medicare?
A: According to Medicare guidelines, each knee orthosis has a different reasonable useful lifetime (RUL). For the braces described in your question, the knee immobilizer without joints (L-1830) has a RUL of one year, and a knee orthosis with adjustable knee joints (L-1832, L-1833) has a RUL of two years. A suspension sleeve is billed using L-2397.All claims for knee orthoses require the following modifiers: KX, Requirements specified in the medical policy have been met; LT, Left side; RT, Right side. No addition codes can be billed for separate payment for L-1830. For L-1832 and L-1833, the addition codes eligible for separate payment are L-2397 (addition to lower extremity orthosis suspension sleeve),L-2795(addition to lower extremity orthosis, knee control, full kneecap) and L-2810(addition to lower extremity orthosis, knee control, condylar). For complete coverage information on all knee braces and the addition codes, visit https://go.cms.gov/2F9vnWX.
Q: I have opened my own facility, and I just received my Medicare Provider Transaction Access Number. Before I start seeing patients and billing Medicare, I want to clarify a few things. Can you provide me a complete description for custom liners payable by Medicare and the codes I use to bill them? Can you also clarify the descriptions for all functional K-levels, so I notate everything appropriately? I was told to come to you if I had any questions about billing and reimbursement.
A: According to Medicare guidelines, "A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist and treating physician." Clinical assessments of beneficiaries' rehabilitation potential must be based on the following classification levels: Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Level 2: Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Level 3: Has the ability or potential for ambulation with variable cadence. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels.
For custom liners you can use L-5673(addition to lower extremity, below or above knee custom fabricated from an existing mold or prefabricated, socket insert, silicone gel, for use with locking mechanism); L-5679(addition to lower extremity, below or above knee custom fabricated from an existing mold or prefabricated, socket insert, silicone gel, NOT FOR USE with locking mechanism); L-5681(Addition to lower extremity below or above knee custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal for use with or without locking mechanism initial only); L-5683(Addition to lower extremity below or above knee custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism initial only (for other than initial, use code L-5673 or L-5679)). For the complete local coverage determination (Medicare LCD) visit https://go.cms.gov/2DkjIm4.
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. While every attempt has been made to ensure accuracy,The O&P EDGEis not responsible for errors. Lake can be contacted at firstname.lastname@example.org.