Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing in O&P can be frustrating. When you have questions, 'Got FAQs?' is there to help keep your billing processes flowing smoothly. This month's column tackles your questions about the change in elastic garment coverage, patient documentation, and the New Jersey parity law.

Q: One of my colleagues told me that Medicare is no longer paying for certain elastic garments. Do you know when this will be effective and which code(s) will no longer be reimbursed?

A: Effective April 1, 2009, the Centers for Medicare & Medicaid Services (CMS) has determined that elastic garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. To see the complete list of the L-Codes that pertain to elastic garments and are no longer payable by Medicare, visit www.cignagovernmentservices.com/jc/pubs/news/2009/0109/cope9205.html

Q: I billed Medicare for L-0450, and my claim was denied as missing information. The representative said that I did not have a valid modifier. I have billed this code in the past and have been paid. I have never used a modifier along with this code. Am I missing something, or did something change and I just am not aware?

A: Effective April 1, 2009, if you bill L-0450, you will either have to use the CG or GY modifier. If the garment billed is made primarily of elastic material, the supplier must add the GY modifier, and the claim will be denied as non-covered. You can then bill the patient for the balance. You should also have an Advance Beneficiary Notice (ABN) form on file informing the patient that this service is non-covered. If a spinal garment is billed using L-0450, L-0454, L-0621, L-0625, or L-0628 and it is made primarily of non-elastic material, such as cotton or nylon, or has a rigid posterior panel, you need to add the CG modifier (policy criteria applied). (Editor's note: For more information, visit www.oandp.com/articles/news_2009-01-29_01.asp)

Q: I am a prosthetic provider in Utah and just opened up my own practice. Where can I find a list of proper paperwork that I should keep in my files for patients that I provide a lower-limb prosthesis for?

A: Noridian Administration Services has a documentation checklist for lowerlimb prostheses. To view the checklist, visit www.noridianmedicare.com/dme/coverage/docs/checklists/lower_limb_prostheses.pdf

Q: I am a provider in the state of New Jersey and have a question pertaining to the new parity law that became effective in our state in April. Can an insurance company put a limit on an O&P claim and state that the patient's DME coverage only has $5,000 maximum coverage? One of the insurance companies is not willing to pay our claim in full.

A: No. The law states that orthotic and prosthetic appliances are not durable medical equipment and are not subject to the dollar or other limits associated with DME. The law does not permit any internal limits on orthotic and prosthetic appliances. If you have any other questions regarding the implementation of this law, contact Gale Simon, assistant commissioner at

Lisa Lake-Salmon is the executive vice president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact or visit www.acc-q-data.com