Got FAQs?

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By Lisa Lake-Salmon

Denials are difficult to identify and time consuming to appeal. With competitive bidding, mandatory accreditation, aging technology, and increased billing errors, running an O&P shop gets more complicated each year.

Q: What is the Medicare rule on a leg that was built for a patient who weighs over 300 pounds? We ordered custom parts to accommodate her. We have had a hard time getting her in for a fitting, and we finally got her in to finish the leg. Now she will not come back and pick up the leg. Every time we call her, she gives us a different excuse. We offered to take the leg to her house, and she makes an appointment but never keeps it. This has been going on since July of 2007. Is there anything we can bill to Medicare?

A: If a custom-made item was ordered but not furnished due to the individual dying or the order being 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 cancelled. You can go to www.cms.hhs.gov/manuals/downloads/bp102c15.pdf or the Medicare Benefit Policy Manual, Chapter 15, Section 20.3, for more information.

Q: Our office was recently audited by a hospital that we have a contract with. During the audit, the hospital asked why we did not have a fitting charge for the off-the-shelf orthosis. Is there a fitting charge for these orthoses at the hospital in addition to the reimbursement for the item being delivered?

A: According to Medicare evaluation of the patient, measurement and/or casting and fitting of the orthosis is included in the allowance for the orthosis (as stated in ankle-foot/knee-ankle-foot orthosis chapter of the Medicare Benefit Policy Manual). Because you have a stipulating contract with this individual hospital, you may be able to seek reimbursement based on your contract with them. I recommend you check your contract and fee schedule with the hospital.

Q: I am licensed in my state as a certified prosthetist. Do I still have to become accredited? If so, do you have a company that you recommend for accreditation, or where can I find a list of accrediting agencies?

A: Licensure is a state-by-state requirement. Licensure and/or certification is granted to a specific individual within a particular division of the company. Accreditation will become a required national standard that covers the entire organizations level of excellence. There are 11 accreditation agencies that have been approved by CMS. They can be found at www.cms.hhs.gov/CompetitiveAcqforDMEPOS.

Q: I recently have been unable to transmit claims to Medicare. We are receiving front-end rejections stating there is an error in the NPI crosswalk. I contacted Medicare and I was told there is a discrepancy between our NPI number and our legacy provider number. I am not sure what I am supposed to do at this point. I would greatly appreciate any assistance you can provide.

A: When you applied for your NPI number, you listed yourself as an "individual" and your legacy provider number has you listed as a "group/organization." Since the information does not match, both of your claims will be rejected on the front end. In this case you will have to apply for a new NPI number. You may do so at https://nppes.cms.hhs.gov/NPPES/Welcome.do

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.