Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing is complicated, and denials are difficult to identify and time consuming to appeal. Don't let these issues slow down your O&P shop. Turn to 'Got FAQs?' to help keep your practice on track.

Q: I submitted a claim to Medicare for a knee CPM and thought my patient had met all the coverage criteria. My claim was denied, and I was told it was missing documentation. Can you help?

A: In order for a knee CPM to be covered, the patient's diagnosis must be V-4365 (total knee replacement). The knee CPM must be put on the patient within two days of the date of surgery. The CPM will be covered for 21 days only. If you are submitting your claim electronically, then you must state the following in the additional documentation:

  • Date of surgery.
  • Date CPM was placed on the patient.
  • Date of discharge from the hospital.

Q: I have a non-diabetic patient whose physician prescribed an AFO brace (L-1960). Will Medicare cover this?

A: According to DMERC, the purpose of a brace is to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. When an AFO for an ambulatory patient and any related addition is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, it will be denied as non-covered. L-1960 is covered for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization for medical reasons and have the potential to benefit functionally.

Q: I am a certified pedorthist from Pismo Beach, California, and recently made a custom AFO for a patient. Before I was able to fit the patient with the AFO, he passed away. Can I still bill for this?

A: If a custom-made item was ordered but not furnished because the individual died or the order was canceled by the beneficiary, payment can be made based on the supplier's expenses. In these cases, the expense is considered incurred on the date the beneficiary died or the date the item was canceled. You can learn more at www.cms.hhs.gov/manuals/downloads/bp102c15.pdf, Medicare Benefit Policy Manual, Chapter 15, Section 20.3.

Lisa Lake-Salmon is the executive vice president of ACC-Q-Data, which provides billing, collections, and practice management software and has been serving the O&P industry for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. For more information, contact lisa@opedge.com