Got FAQs?

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By Lisa Lake-Salmon

The future of your practice depends on knowledgeable billing and collection information. Understanding the full aspect of billing guidelines and procedures will effectively increase your reimbursement. This informative column will help providers and their staff with a better understanding of billing procedures and reimbursement strategies.

Q: I billed a breast prosthesis L-8030 to Medicare and received a denial for CO-57 (same or similar). How often is a patient allowed to receive a breast prosthesis from Medicare?

A: According to Medicare guidelines, a patient is allowed one breast prosthesis every two years. I suggest when documenting the patient's history, you should specify when the patient received her last breast prosthesis. According to a Region C Medicare representative, if this is documented properly, you can then send the claim to review and they would consider payment if you have documentation of the patient's history, showing that inappropriate information was given by the patient. If Medicare still denies your claim, you may request a telephone hearing.

Q: I am a Region D provider and received payment from Medicare for a patient who, we have since learned, has other insurance as primary. We would like to return the money to Medicare even though they did not request it from us. Please let me know what we need to do.

A: Cigna, the Medicare administrator for Region D, has a form for voluntary overpayment refunds. This form can be found in Chapter 12 of the supplier manual under the section titled "Overpayments and Refunds."

Q: I recently received payment on claims that were for DOS May and June of 2003. I noticed that we were not paid according to the fee schedule, and we don't know why.

A: The law requires that the claim be filed no later than the end of the calendar year following the year in which the service was furnished. However, if the services were in the last three months of the year, then claims must be filed no later than December 31 of the second year following the year in which the services were rendered. According to the Omnibus Budget Reconciliation Act of 1989, assigned Medicare claims must be filed within one year from the date of service or the payment will be reduced by 10 percent.

We invite readers to ask any questions you have regarding billing, collections, or any other information. To send your questions or for more information, contact:lisa@westernmediallc.com

Acc-Q-Data provides billing, collections, and practice management software serving the O&P industry nationwide for over a decade.

Lisa Lake-Salmon is Executive Vice President, Acc-Q-Data Inc.