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. Whether your question is about billing, collections, procedures, or guidelines, count on "Got FAQs?" to give you the answers you need to stay on top of the game.

Q: We provided a patient with a leg brace roughly three months ago. At the time we had the patient sign an Advance Beneficiary Notice (ABN) form. The patient is returning for an adjustment to the brace. Do we need to have the patient sign another ABN form?

A: According to DMERC, if you have a plan of care for your patient that covers a certain date range and the patient's condition does not change, the ABN form you have on file would still be valid.

Q: We were recently contacted by a patient whose main residence is in Puerto Rico. Will Medicare pay for services provided to a patient who does not reside within the U.S. mainland?

A: If you are a Medicare provider, you can be reimbursed for services provided to patients who live in Puerto Rico as long as the medical guidelines are met. The Centers for Medicare & Medicaid Services (CMS) recognizes Puerto Rico, American Samoa, the Virgin Islands, Guam, and the Northern Mariana Islands as U.S. territories.

Q: I am a Medicare provider in New Jersey. What are the guidelines for billing a replacement brace to a patient who has already had the same or similar brace in the last year. Will Medicare pay for it if there is a change of condition, and if so how is it billed?

A: You will need to file your claim as you normally would to receive a CO-57 denial (same or similar). Once you receive your denial, you will need to send in a review/appeal with additional documentation showing the old brace is no longer adequate, due to wear and tear, patient weight gain/loss and the brace no longer fits, or damage or theft.Medicare will consider paying for another brace if it feels the information submitted deems it medically necessary.

Q: I am a billing manager for a large O&P practice in Michigan and have been asked to find out what our Provider Taxonomy Code is. Is there a list I can go to that will tell me what taxonomy we should use? I am not sure what this is and where I would find a listing of the codes.

A: The Health Care Provider Taxonomy Code set divides healthcare providers into hierarchy groupings by type, classification, and specialization, and assigns a code to each grouping. These codes are not assigned to healthcare providers; instead healthcare providers select the taxonomy code that most closely represents their education, license, or certification. The taxonomy code set can be found at

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