Billing and Collections Q&A
December 2011 Issue
Running an O&P facility in today's landscape of enhanced scrutiny and changing billing requirements can leave even the most seasoned billing professional feeling frustrated. If you have a billing question, "Got FAQs?" can help you get the answers you need. This month's column addresses your questions about Medicare's Round 2 competitive bidding, payment to nonparticipating providers, and billing for walking boots.
Q: I recently read an article regarding Round 2 of Medicare's competitive bidding program that mentioned there were additional products that would be affected. Do you know what additional products or devices are affected, and where I can find information on Round 2 competitive bidding?
A: On August 24, 2011, the Centers for Medicare & Medicaid Services (CMS) announced the next steps for the expansion of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program to include Round 2 and the national mail-order competitions. The items affected are oxygen, oxygen equipment, and supplies; standard (power and manual) wheelchairs, scooters, and related accessories; enteral nutrients, equipment, and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories; hospital beds and related accessories; walkers and related accessories; negative pressure wound therapy pumps and related supplies and accessories; and support surfaces (Group 2 mattresses and overlays). For more information visit www.oandp.com/link/118
Q: Is it okay to obtain payment in full for repairs from a patient without an Advance Beneficiary Notice (ABN)? We would submit a "courtesy claim"/non-assigned claim to Medicare. I am familiar with the repair/replacements policy, but we are a nonparticipating provider. I was under the impression that nonparticipating providers must follow the same rules as participating providers based on the decision to submit claims to Medicare.
A: Yes, you may obtain payment directly from the patient without an ABN. According to the Medicare Provider Manual, Chapter 2, Section 6, Participating/Nonparticipating, "Suppliers who choose not to sign the participation contract are referred to as nonparticipating suppliers. Nonparticipating suppliers may choose to accept assignment on a claim-by-claim basis except where CMS regulations require mandatory assignment (i.e., Medicare covered drugs, home dialysis equipment and supplies, Indian Health Services)." If you choose to accept assignment on a claim as a nonparticipating provider, however, you must follow the same rules as participating providers. For more information, visit www.oandp.com/link/119
Q: When a patient is diagnosed with a stress fracture or fracture of any kind below the knee, can you fit the patient with a walking boot and bill L-2114 for the device? Or, regardless of the diagnosis, should a walking boot always be billed as L-4360 or L-4386? I noticed several of our customers' practices are billing L-2114 for a walking boot only if a fracture is involved.
A: An AFO described by codes L-1900; L-1902-L-1990; L-2106-L-2116; L-4350; L-4360; L-4386; and L-4631 are covered for ambulatory patients with weakness or deformity of the foot and ankle who require stabilization for medical reasons and have the potential to benefit functionally. The descriptions for the codes you asked about are as follows:
- L-2114: Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment.
- L-4360: Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment.
- L-4386: Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment.
To ensure you are coding the device you provided correctly, I suggest that you go to the Medicare Pricing, Data Analysis and Coding (PDAC) website which can be accessed at www.oandp.com/link/120. You can then search the DMEPOS Product Classification List by entering the manufacturer/distributor, product name, and product/model.
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