Got FAQs?

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By Lisa Lake-Salmon
Lisa Lake-Salmon

Billing for an O&P practice seems to get more complicated by the day. Count on "Got FAQs?" to help answer your toughest questions. This month's column addresses your questions about billing codes for spinal electrical osteogenesis stimulators, Medicare Supplier Standards, and L-Code additions for AFOs.

Q: We are a Florida O&P facility, and we recently started billing for spinal electrical osteogenesis stimulator (E-0748). Every claim we billed was denied due to a missing Certificate of Medical Necessity (CMN). I am unable to locate this document so we can have the referring physician fill it out. Can you also provide me with any information you have on the coverage criteria for this item?

A: A spinal electrical osteogenesis stimulator (E-0748) is covered only if one of the following criteria are met:

  1. Failed spinal fusion (ICD-9 code V45.4) when a minimum of nine months has elapsed since the last surgery, or
  2. Following a multilevel spinal-fusion surgery (ICD-9 code V45.4), or
  3. Following spinal-fusion surgery (ICD-9 code V45.4) where there is a history of a previously failed spinal fusion at the same site.

A spinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria above are met. You may find the CMN required when billing for electrical osteogenesis stimulator at www.cms.gov/cmsforms/downloads/CMS847.pdf. For a complete list of CMNs required by Medicare, visit www.cgsmedicare.com/jc/pubs/pdf/Chpt4.pdf

Q: We are a Kentucky O&P facility and have a question concerning Medicare Supplier Standard 11, which states, "A supplier must agree not to initiate telephone contact with beneficiaries, with few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business."

  1. Exception: "The individual has given written permission to the supplier or the ordering physician or non-physician practitioner to contact them concerning the furnishing of a Medicare-covered item that is to be rented or purchased."
  2. Exception: "The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to coordinate the delivery of the item."

Based on this information, my question is this: When a physician calls and requests that we contact the patient to schedule an appointment to deliver an item the physician is prescribing, are we allowed to contact the patient or is that a violation of the standard?

A: Supplier Standard 11 states: "A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician's oral order unless an exception applies."

Based on the information you have provided, it's not clear whether or not you would qualify under the second exception you listed. I recommend that you obtain the information required in the first exception before initiating telephone contact.

Q: I have a question regarding AFOs. I have been receiving Recovery Audit Contractor (RAC) audits to refund money for addition codes used with AFOs. Can you please tell me where I can find a list of what addition codes I can use for AFOs? I found on the Centers for Medicare & Medicaid Services (CMS) website that L-Code additions to AFOs and KAFOs (L-2180 through L-2550, L-2750 through L-2768, and L-2780 through L-2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary. Does this mean no addition codes for any AFO are allowed?

A: Medicare pays for addition codes for AFOs. What CMS is indicating is that the base code must be considered reasonable and necessary and the addition codes must also be considered necessary. Suppliers must add a KX modifier to the AFO base and addition codes only if all of the coverage criteria in the "Indications and Limitations of Coverage and or Medical Necessity" section of this policy have been met and evidence of such is retained in the supplier's files and available to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) upon request. The order must list the unique features of the base code that is billed plus every addition that will be billed on a separate claim line. The medical record must contain information that supports the medical necessity of the item and all additions that are ordered. The complete Local Coverage Determination (LCD) for AFOs can be found at http://tinyurl.com/4y45xz9

Lisa Lake-Salmon is the 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