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 forms required for a new facility and billing for L-0631 and L-0637.

Q: We are opening an additional location for our practice, and I am not sure what paperwork I need to fill out. Do we need to notify Medicare, or can we use the same Medicare provider number, surety bond, and liability insurance for both locations? Do we need to inform anyone other than Medicare regarding the new office?

A: You will need to obtain a National Provider Identifier (NPI) for the new patient care facility and fill out the Medicare Enrollment Application, form 855S, if you are currently enrolled in Medicare as a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier and (1) need to enroll a new business location using the same tax identification number already registered with the National Supplier Clearinghouse Medicare Administrative Contractor (NSC MAC), or (2) need to enroll a new business location using a tax identification number not currently enrolled with the NSC MAC. To access form 855S, visit www.oandp.com/link/250. A supplier must have at least $300,000 in comprehensive liability insurance that covers the supplier's place of business, all customers, and employees. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. A supplier must meet the surety bond requirements specified in 42 CFR. 424.57(c). There are some exceptions to the surety bond requirement listed under this section that could pertain to your practice. A state-licensed O&P practitioner in private practice who makes custom-made orthotics and prosthetics is exempted from the surety bond requirement if (1) the business is solely owned and operated by the O&P practitioner, and (2) the business is only billing for orthotics, prosthetics, and supplies. To access this information, visit www.oandp.com/link/251. Suppliers must also notify their accreditation organization when they open a new DMEPOS location (supplier standard 23). The supplier must enroll separate physical locations it uses to furnish Medicare-covered DMEPOS, with the exception of locations that are used solely as warehouses or repair facilities. The accreditation organization may accredit the new supplier location for three months after it is operational without requiring a new site visit. Each location must be separately accredited to bill Medicare.

Q: We are located in Hawaii, and we bill to Medicare Jurisdiction D. Lately we have received many denials on codes L-0631 (LSO sag-coro rigid frame prefab) and L-0637 (LSO sag-coronal panel prefab). Our claims are being denied because coverage criteria indicated in spinal orthoses local coverage determination (LCD) L11459 were not met, or the proof of delivery provided was invalid. I do not understand these denials. The durable medical equipment (DME) item does not seem to have the required coding verification or I am unable to verify the DME item as being listed on the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor website. Is Medicare no longer covering these items? Why are we receiving so many denials, and what do we need to do to stop them?

A: The Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department is conducting a widespread complex review of Healthcare Common Procedure Coding System (HCPCS) codes L-0631 and L-0637. This is the reason for the influx of denials you are receiving. Lumbar-sacral orthoses (LSOs) that are PDAC coded as L-0631 and L-0637 are covered when they are ordered to reduce pain by restricting trunk mobility, to facilitate healing following an injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise support weak spinal muscles or a deformed spine. Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes L-0631or L-0637 are those that are specified in the Product Classification List on the PDAC contractor's website. Read the widespread complex review to gain a better understanding as to why your claims are being denied. To access this review, visit www.oandp.com/link/252

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