Billing and Collections Q&A

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By Lisa Lake-Salmon

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 or a question about a denial, "Got FAQs?" can help you sift through the confusion and get you the answers you need. This month's column addresses your questions about Medicare and Medicaid co-payments, ABN forms, and the new code to replace L-5311.

Q: I would like clarification on patient balances that are due for either coinsurance or deductibles. I contacted Medicare and spoke with two different representatives who gave me different answers. The first representative stated that after Medicare processes the claim it is then up to the provider whether to bill the patient for any balance due. Another representative stated that the provider can only give discounts or waive any balances due if there is a hardship letter on file. The first representative did not mention any such letter. Which one is correct, and where can I obtain more information so I can have a copy for my records?

A: As a general rule, a provider should not waive co-payments or deductibles. In the context of Medicare and Medicaid patients, this is prohibited in the absence of demonstrating financial hardship of the patient. Waiver of co-payments and deductibles may be viewed as a potential kickback and can be considered Medicare fraud or grounds for disciplinary action against the provider who waives the co-payment or deductible. To read more about this, visit Chapter 4, Sections, 4.6.1, and in the Centers for Medicare & Medicaid Services (CMS) Medicare Program Integrity Manual address waiver of Medicare co-payments.

Q: I read that there is a new Advanced Beneficiary Notice of Noncoverage (ABN) form. Where can I find information on this? We are a Medicare provider, and I want to make sure we have all acceptable forms.

A: On September 20, 2011, CMS issued the following statement: Extension of mandatory use date for REVISED ABN, FORM CMS-R-131, posted for download on May 16, 2011. Mandatory use date: January 1, 2012. In order for providers and suppliers to have time to transition to using the newly posted notice, mandatory use of this version begins on January 1, 2012. All ABNs with the release date of March 2008 that are issued on or after January 1, 2012, will be considered invalid. The latest version of the ABN and the instructions for use can be downloaded at

Q: I recently submitted a claim to Cigna Medicare, and the entire claim was paid other than code L-5311. I have used this L-Code before and have never received a denial. Am I missing something?

A: On December 5, 2011, CMS issued Healthcare Common Procedure Coding System (HCPCS) code updates for 2012. Effective January 1, 2012, L-5311 (knee disarticulation [or through knee], molded socket, external knee joints, shin, SACH foot, endoskeletal system) has been discontinued for use and has been crosswalked to L-5312 (knee disarticulation [or through knee], molded socket, single axis knee, pylon SACH foot, endoskeletal system). Information on all added and deleted codes for 2012 can be viewed at

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