Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing for O&P devices and care is complicated. When you have questions, count on "Got FAQs?" to help keep your claims on track. This month's column answers your questions about prosthetic devices not delivered until after the patient entered an SNF, and medical necessity for custom knee orthoses.

Q: We are an O&P office located in Alabama. We recently received a denial for a prosthetic device that we provided to a patient who is now in a skilled nursing facility (SNF). Could you clarify Medicare's policies about who is responsible for billing for the prosthesis when the item was ordered while the patient was at home but was delivered after he or she entered an SNF?

A: According to Medicare guidelines, when a beneficiary requires a prosthesis while in the home and then enters an SNF for a covered Part A stay, the Durable Medical Equipment Regional Carrier (DMERC) would be billed by the provider who supplied the device, not the SNF. I would recommend that your records indicate that the medical necessity was established while the patient was still at home. However, customized prosthetic devices are usually excluded from what is considered consolidated billing. To view what L-Codes are excluded from consolidated billing while a patient is in an SNF, visit www.oandp.com/link/262. For additional information, read MLN Matters article SE0437, titled "Skilled Nursing Facility Consolidated Billing as It Relates to Prosthetics and Orthotics," which can be found at www.oandp.com/link/263

Q: We are a new provider of custom knee orthoses. We are trying to keep our records as accurate and concise as possible in the wake of all the Medicare Recovery Audit Contractor (RAC) audits. What documentation do we need to have in the patient's file to justify why we are providing a custom knee orthosis rather than a prefabricated orthosis? Can you clarify the medical necessity that the patient's file should have when billing for L-1844 (knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated)?

A: When billing for L-1844, your documentation should clearly state the physical characteristic that requires the use of a custom-fabricated device instead of a prefabricated brace. For Medicare to consider L-1844 medically necessary, the patient's records should reflect either deformity of the leg or knee, size of the thigh and calf, or minimal muscle mass upon which to suspend an orthosis. If a custom-fabricated orthosis is provided but the medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the custom-fabricated device will be denied as not reasonable and necessary. Custom-fabricated orthoses such as L-1844 are not reasonable and necessary in the treatment of knee contractures in cases where the beneficiary is nonambulatory. The supplier must maintain detailed records describing the need for, and nature of, all modifications including a detailed explanation of the justification for any component. For complete information on billing and medical necessity for knee braces, visit www.oandp.com/link/264

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