I would like to submit the following question to the list for consideration. I will beg your pardon from the outset if this begins to get to long, but please…it is an important issue from where I am…SO HERE GOES…
I am presently in a conversation with a couple of local insurance company’s about coding in general, ie base code & add-on codes and combining the two when describing a “complete” device. Unfortunately because of recent past events with a local O&P facility, these insurance company’s have a knee jerk reaction and assume fraud &/or abuse (unbundling…double billing) when they see numerous codes applied to a “single” device. Especially if that device is “manufactured” by an outside company (GII, CTi, Townsend etc…etc…), and not made in house . .I have made significant head way in my discussions with them, and have been able to maintain a very civil and professional conversation with them as we have discussed specific coding issues, but there are some significant sticking points.
The insurance companies are taking the position that if I “purchase” a device with the add-on characteristics already included in the manufactured device, then I cannot use add-on codes to be reimbursed for those additional characteristics above the base code descriptor, because they are already existent in the manufactured item when I receive it. Specifically… just one example… they are taking the position that the use of the L2275, L2755 are acceptable add-on codes with a GII Select, but the use of the L2435 is not, because the orthosis “comes with that joint”. Since the orthosis “comes with that joint already on the orthosis”, I cannot use the L2435 when describing the “complete” device. Yet if I fabricate an L1844, and add a polycentric joint to the system during the in-house manufacturing, then they will allow the L2435 add-on. (Maybe I’m onto something here?) Typical insurance company logic? I maintain that the L2435 cost is rolled into the cost I am paying for the orthosis when I buy it from the manufacturer…passed on if you will. One of the insurance companies is telling me that GII specifically stated that it “does not support the use of L2435 with their brace”?
My argument with the insurance companies is that it doesn’t matter what ANY manufacturer says, that it is based on the legal language of the L-codes, which is determined by Medicare, and that I am ultimately responsible for the correct application of the codes per the devices provided. They yield to the fact that they will hold me responsible for the codes I use, and not the manufacturer whether they recommend the codes or not. The L1844 base code does not describe a polycentric joint, rather it describes an adjustable flexion/extension joint, thus using the L2435 code (whether I manufacture the orthosis, or pay someone to manufacture it for me) is an appropriate add-on as long as there is a polycentric joint included in the system. Ultimately I am absorbing the cost of having the polycentric joint included in the system, whether I put it in, or a manufacturer does. I have maintained that if the characteristic is not included in the base code description as defined by Medicare, and it is medically necessary, then the add-on is appropriate. This was confirmed for me during an informal conversation at an L-coding seminar, specifically per the GII…but…the insurance company is telling me GII is saying “NOT APPROPRIATE”.
AM I TOTALLY OFF MY ROCKER HERE !!!!!!
I am gradually moving up the feeding chain of these insurance companies, and actually am having conversations with the “powers that be” and ultimately will decide my coding fate….
A side line” wrench in the works” is that the local CTi rep, & local Don Joy rep, were “allowed” by one of the insurance companies to provide the orthosis for just the base code price, thus receiving “referrals” from the insurance company. I know this to be true because the insurance company questioned my use of add-on’s with my orthosis “because the reps only bill at base code prices, so why should we have patients go to you”.(and they specifically mentioned DJ & CTi, and our local GII guy told me he turned their offer down !!)
any help, confirmation, correction, per the aforementioned would be greatly appreciated…
Mike M.
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