Billing and Collections Q&A

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By Lisa Lake-Salmon

Billing for O&P devices seems to get more complicated by the day. Count on Got FAQs? to help answer your toughest questions. This month's column addresses your questions about the difference between custom-fitted and off-the-shelf orthoses and how to code them correctly, and billing for replacement knee orthoses.

Q: I started working for an orthotist a few months ago. I have read numerous articles referring to custom-fitted orthoses and off-the-shelf (OTS) orthoses. How do I differentiate between custom and OTS orthoses? Do you have a list that shows which codes to use if an item is custom or OTS? Also, I billed for an OTS orthosis using L-1600 (hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise), but my claim was denied as it was not custom fitted. I was told I did not use the correct crosswalk code, but I don't understand what this means. Thank you.

A: On April 30, Medicare issued a revised bulletin, Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces). According to a press release from Medicare, "Some Custom Fitted codes do not have corresponding OTS codes. If items described by these codes are furnished off-the-shelf without custom fitting or with fitting performed by someone without expertise in fitting, the corresponding code [crosswalk code] for the broader category of orthotics not otherwise specified in the HCPCS [Healthcare Common Procedure Coding System] (e.g., L-1499 for Spinal Orthosis, Not Otherwise Specified) should be used. The supplier should indicate in the narrative field for the claim that the orthotic was furnished off-the-shelf."

You received a denial because L-1600, along with L-1610 (hip orthosis, abduction control of hip joints, flexible, (frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) and L-1620 (hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise), needs to be coded as L-1499 since it was provided as an OTS device. To view a list of codes for custom-fitted devices and the crosswalk codes for OTS orthoses, visit www.oandp.com/link/319.

Q: A year and a half ago, we provided a patient with a knee brace coded L-1845 (knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise). The patient came to our office and said the brace was destroyed in a house fire recently. Can we bill Medicare for a new brace?

A: In certain situations, and with appropriate documentation, Medicare allows for a replacement orthosis to be provided to a patient who has had the device for less than three years, which is normally considered the reasonable useful lifetime of the brace. If the brace is lost, damaged beyond repair, if the cost of repair is greater than 60 percent of the allowable amount, or if there is a documented physiological change in the patient's medical condition, the replacement may be covered. According to Medicare, irreparable damage is considered when there is a specific incident or accident, such as a natural disaster, documented accident, or documented theft. In all cases, a new physician's order is required to support the continued need of the brace. The medical records must include a reason for the replacement, a statement from the beneficiary about the condition of the irreparable or lost item, and police reports, as appropriate. You must use specific modifiers when billing a claim for replacement items. Use the HCPCS code, the RT (right) or LT (left) designation if appropriate, and the RA modifier (replacement of a durable medical equipment item). The RA modifier indicates you are replacing the item within the expected lifetime and you have all the documentation to support the item is beyond repair, lost, stolen, or there is a documented physiological change to the patient.

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.