Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing for O&P devices and care is complicated. When you have questions, count on "Got FAQs?" to help keep your claims on track. This month's column addresses your questions about PECOS claims rejection, O&P modifiers, and services for SNF patients.

Q: Has the Centers for Medicare & Medicaid Services (CMS) posted or started giving providers notice when claims rejection begins if an ordering/referring provider does not have a record in the Provider Enrollment, Chain and Ownership System (PECOS)?

A: According to a CMS press release, "At this time CMS has not turned on the automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS. CMS is working to resolve backlog and other systems issues and will provide ample advance notice to the provider and beneficiary communities before CMS begins any such automatic denials." For more information regarding enrollment, common questions, and using PECOS, visit or

Q: I am a new billing manager for a Region C O&P practice. I have received denials for incorrect modifiers. Can you provide me with any resources I can use to find the correct modifiers and their descriptions for O&P?

A: The Cigna Government Services (CGS) supplier manual, chapter 16, provides information on all durable medical equipment (DME) and O&P modifiers, with complete descriptions for each, at You may also use Medicare's Modifier Tool on the Region C website by going to

Q: In recent months, we have received denials for prosthetic devices we provided to patients residing in a skilled nursing facility (SNF). I was under the impression that a prosthetic device was covered when provided to such patients. Did Medicare recently change their guidelines?

A: On August 2, Medicare issued the following statement: "Since Monday, April 4, our claims processing system has been erroneously denying claims for certain custom prosthetic devices. CMS is issuing instructions to correct this processing error, but the correction will not be implemented until Sunday, January 1, 2012. In the interim, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) will reprocess any claims for custom prosthetic devices (identified by the "L" series of the Healthcare Common Procedure Coding System [HCPCS] codes) that were inappropriately denied when such claims are brought to their attention." Medicare guidelines state that Part B payment can be made for prosthetics, orthotics, and supplies when they are furnished to a beneficiary who is in a non-covered, Part A stay at a hospital or SNF. An exception to this policy is when certain customized prosthetic devices are furnished to beneficiaries residing in a covered Part A SNF stay, as these items were carved out of the SNF Consolidated Billing provision by the Balanced Budget Refinement Act of 1999 (BBRA, PL 106-113, Appendix F, Section 103). To read the press release, visit

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