Billing and Collections Q&A

Home > Articles > Billing and Collections Q&A
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 billing for spinal osteogenesis stimulators and durable medical equipment fee schedules for workers' compensation and no-fault claims.

Q: We recently started billing for spinal electrical osteogenesis stimulators (E-0747). Every claim we have billed has been denied for incorrect modifiers and invalid diagnosis codes. What are the coverage criteria for this item, and what modifiers need to be used?

A: A nonspinal electrical osteogenesis stimulator is covered if one of the following criteria are met: Nonunion of a long bone fracture (International Classification of Diseases, Ninth Edition (ICD-9) codes 810.00-810.13, 812.00-813.93, 815.00-815.19, 820.00-821.39, 823.00-824.9, 825.25, and 825.35) defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator; or failed fusion of a joint other than in the spine (ICD-9 code V45.4) where a minimum of nine months has elapsed since the last surgery; or congenital pseudarthrosis (ICD-9 code 755.8). Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days. Each set of radiographs should include multiple views of the fracture site and a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs. A nonspinal electrical osteogenesis stimulator will be denied as not medically necessary if none of the criteria above are met. You need to use the NU and KF modifiers. You also need to have the referring physician complete a certificate of medical necessity (CMN), which can be accessed at www.oandp.com/link/170

Q: We are durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers located in the state of New York. A group of physicians in our area recently started providing orthoses to patients directly, and as a result, referrals from this physicians' group have decreased. One of the physicians contacted us and requested that we provide devices to the physician's patients who are covered by workers' compensation or no-fault insurance since the practice will only be reimbursed for the cost of these devices. Does the durable medical equipment (DME) fee schedule apply to physicians or only to DME and O&P providers?

A: The Office of General Counsel issued the following opinion on April 6, 2009, representing the position of the New York State Insurance Department on Applicability of Workers' Compensation Board (WCB) Directive to Durable Medical Equipment Fee Schedule in No-Fault Claims: Since 11 N.Y.C.R.R. [New York Codes, Rules, and Regulations] 68.1(b)(1) (Regulation 83) adopts the WCB's fee schedules and ground rules for no-fault billing and reimbursement, and because physicians are excluded from the durable medical equipment (DME) fee schedule, the WCB's directive interpreting the DME fee schedule applies to charges arising from no-fault claims, in accordance with the clear intent of Insurance Law § 5108(a) to ensure that no-fault health services are reimbursed in accordance with the WCB fee schedule. Thus, the DME fee schedule applies only to DME suppliers and not to medical providers supplying DME directly to patients, for purposes of reimbursing the cost of DME under the no-fault law. For more information, visit www.oandp.com/link/171

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