A Guide to Getting O&P Repairs and Replacement Coverage, Part II

O&P practices provide thousands of dollars in uncompensated repairs each year because of insufficient chart documentation to allow coverage. This article series will provide a summary of documentation requirements for repairs and replacement, proper coding for repairs and replacement, and sources of guidance that dictate the requirements The table of contents provides a guide to the three parts of the series to help enable you to navigate to the information you are searching for. Table of Contents Part I: General Document Guidance History of the Device Clinician Evaluation Documentation Assessment of Needs When Is a New Physician Order Required? Documentation for Continued Medical Need (Policy Article A55426) Part II: Definitions of Coverage Criteria What Is a Repair and When Is It Covered? What Is a Replacement and When Is It Covered? Summary of Medical Documentation Required for Coverage of Repair/Replacement Part III: Repairs and Replacement Coding Coding and Documenting Labor Involved to Perform Repairs How to Code for Replacement Parts Replacement Documentation Required for Prosthetic Replacement Documentation Required for Orthotic Replacement Pricing/Billing and Reimbursement Issues Modifiers Allowable Amounts Not Otherwise Specified Codes Payment Methodologies for Minor Parts/NOS Codes Medicare Medicare Gap Filling Explained Co mmercial Insurers Regulatory Mandates Conclusion In part I of this series, we discussed the applicable general documentation requirements described in Policy Article A55426 and offered suggestions as to best practices for O&P. In this installment, we look at specifics of coverage criteria for repairs and replacement. What Is a Repair and When Is It Covered? According to the Medicare Benefit Policy Manual , to repair means to fix or mend and to put the equipment back in good condition after damage or wear. Repairs to equipment a beneficiary owns are covered when necessary to make the equipment serviceable but are not covered for repairs of previously denied equipment. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess. ( Benefit Policy Manual, Chapter 15, Section 110.2) Another important distinction is that “routine, periodic maintenance, such as testing, cleaning, regulating, and checking is not covered.” In the case of repairs to a beneficiary-owned durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item, if Medicare paid for the base item initially, medical necessity for the base item has been established. With respect to Medicare reimbursement for the repair, there are two documentation requirements: The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary (see Continued Medical Need section); and, Either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary. The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality. What Is a Replacement and When Is It Covered? According to the Medicare Benefit Policy Manual, DMEPOS replacement refers to the provision of an identical or nearly identical item. Equipment the beneficiary owns or is a capped rental item may be replaced (i.e., it is covered) in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire or flood). (Note: The Medicare Benefit Policy Manual addresses all DMEPOS, but the O&P LCD and Policy Articles have additional coverage requirements to consider. While damaged prosthetic component replacements are covered, irreparable wear for orthotic services refers to deterioration sustained from day-to-day use over time where a specific event cannot be identified to have caused the damage; replacement in this situation is noncovered.) Per the Medicare Benefit Policy Manual , the reasonable useful lifetime (RUL) of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACS may determine the RUL of equipment, but in no case can it be less than five years. The computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the RUL of the equipment. During the RUL, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. ( Benefit Policy Manual, Chapter 15, Section 110.2) “Irreparable damage” is often confused with “irreparable wear.” Irreparable damage, like loss or theft, is a rare, unexpected event that is an exception to the RUL rule. Medicare considers irreparable damage to have occurred when an item is damaged beyond repair by a specific incident or accident. For example, a power wheelchair falls off of a van while traveling down the highway. If the cost to repair the wheelchair exceeds the cost of a new wheelchair, Medicare would cover the replacement. Reasonable Useful Lifetime-Clarification (Rev. 11/01/2013) is a DME PDAC advisory article that further delineates irreparable wear versus irreparable damage. It clarifies that replacement of prosthetic devices is not restrained by continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is necessary. The 11/01/2013 DMEPDAC Advisory continues: Accidental damage must be distinguished from wear, especially in orthotic replacements. For example, the drive motor in a power wheelchair breaks down after three years of use because the patient uses the power wheelchair daily to go to work and school and for mobility at home. There is no specific incident that can be identified that caused the motor to stop other than the daily wear on the motor. In this example, Medicare would not cover a replacement wheelchair because the statutory five-year RUL has not expired. However, Medicare would cover repair of the wheelchair up to but not exceeding the cost of replacement of the wheelchair. There are two exceptions to the above guidance that apply to limb prostheses and external breast prostheses. For limb prostheses, a change to the RUL rule was made when the Benefits Improvement and Protection Act of 2000 amended §1834(h)(1) of the Social Security Act by adding a provision (1834 (h)(1)(G)(i)) that requires Medicare payment to be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or RUL restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is necessary. In the case of orthotics, the specific LCD and Policy Article create additional replacement coverage conditions that must be considered when replacing an orthotic device. Summary of Medical Documentation Required for Coverage of Repair/Replacement If the base equipment as originally prescribed is still appropriate: The original standard written order (SWO), with the length of need indicating the device is still expected to be in use Documentation in the orthotist/prosthetist note about why the repair is necessary (issue with device, impact on patient, what is required to return the device to optimal function) Documentation to support the coding billed (actual repair time labor documented, description of the repair performed, and the minor parts used, if any, to make the repair) If the base equipment is no longer appropriate, or if a component part Healthcare Common Procedure Coding System (HCPCS) code being replaced was not a code on the original SWO, documentation should include: A new SWO Physician documentation to explain the need to replace the component and the continued medical necessity for the device as now prescribed Orthotist/prosthetist documentation about why the repair or replacement is necessary (issue with device, impact on patient, what is required to return the device to optimal function) Potentially a signed, dated Advance Beneficiary Notice for orthotic devices replaced within the RUL Documentation to support the coding billed (HCPCS or minor parts codes/labor codes), and when the billed amount is a sizable portion of the cost of a device, documentation to demonstrate that repair is less than 60 percent of the payer’s cost for a new device. Susi Ebersbach, MT (ASCP), MBA, provides independent consulting and has over twenty years of experience in O&P reimbursement topics, working with both providers and manufacturers. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.

A Guide to Getting O&P Repairs and Replacement Coverage, Part II

A Guide to Getting O&P Repairs and Replacement Coverage, Part III

A Guide to Getting O&P Repairs and Replacement Coverage, Part I

A Guide to Getting O&P Repairs and Replacement Coverage, Part I

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A Guide to Getting O&P Repairs and Replacement Coverage, Part II

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A Guide to Getting O&P Repairs and Replacement Coverage, Part III

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A Guide to Getting O&P Repairs and Replacement Coverage, Part I

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