Billing and Collections Q&A

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By Lisa Lake-Salmon

Denials can be frustrating to handle and difficult to appeal. Count on "Got FAQs?" to provide you with the information you need to save time and frustration. This month's column answers your questions about Medicare referring provider edits and TLSO codes that became effective January 1.

Q: I work for an O&P provider in Alabama. He said I have to verify information about any physician who refers Medicare beneficiaries to us with an O&P prescription to be filled. He said we could stop getting paid by Medicare if we do not do this. Can you please tell me where I can get this information and clarify what it is for?

A: Effective January 6, Medicare turned on the edits to deny payment for Part B durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims that fail the ordering/referring provider edits. The edits will determine: (1) if the ordering/referring provider (when required to be identified in Part B clinical laboratory and imaging, durable medical equipment (DME), and Part A Home Health Agency (HHA) claims) has a current Medicare enrollment record that contains a valid National Provider Identifier (NPI); (2) is a provider type that is eligible to order for or refer Medicare beneficiaries; and (3) that the name and NPI match.

To read the complete article, "Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency Claims," visit www.oandp.com/link/255

To verify if your referring physician is listed correctly and locate instructions, use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To access the site, visit www.oandp.com/link/256. There is also a "Dear Physician" letter you can send to your referring physicians that explains the information needed. To access the letter, visit www.oandp.com/link/257

Q: We are located in Texas and provide thoracic-lumbarsacral orthoses (TLSOs). I am relatively new at billing for these services. Can you tell me if there are any new or deleted codes for TLSOs for 2014? Where can I find this information?

A: There are four new codes added for TLSOs. The added Healthcare Common Procedure Coding System (HCPCS) codes were effective January 1. The codes and descriptions follow:

L-0455: TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf.

L-0457: TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel, and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf.

L-0467: TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf.

L-0469: TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf.

To view the 2014 HCPCS updates list, which includes new, revised, and discontinued HCPCS codes, visit www.oandp.com/link/258

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