Billing and Collections Q&A

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By Lisa Lake-Salmon
denied

Denials are difficult to identify and time consuming to appeal. Count on Got FAQs? to help ensure you are using the most current information when preparing your claims. This month's column answers your questions about which codes to use when billing for custom-fitted versus off-the-shelf thoracic-lumbar-sacral orthoses and documentation to include when billing for spinal orthoses.

Q: My husband is a provider in New Jersey, and I just started working in his office a few months ago. I am trying to understand the difference between custom-fitted orthoses and off-the-shelf (OTS) orthoses. My husband is providing a patient with a thoracic-lumbar-sacral orthosis (TLSO), and I would like to know which codes to use if the TLSO is custom fitted or OTS. The codes we always billed for were L-0454 (TLSO flex prefab sacrococ-T9); L-0456 (TLSO flex prefab); L-0466 (TLSO rigid frame pre soft ap); and L-0468 (TLSO rigid frame prefab pelv). If these are the codes I use for custom-fitted braces, then which codes would I use if the device we provide is OTS? Thank you.

A: On July 2, Medicare revised an April 30 bulletin for Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces). Please note that some custom-fitted codes do not have corresponding OTS codes. If items described by these codes are furnished OTS without custom fitting or with fitting performed by someone without expertise in fitting, the corresponding code for the broader category of orthoses not otherwise specified in the 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 orthosis was furnished OTS. Not all new codes listed have a corresponding medical policy.

The codes you provided above all have new OTS codes: For L-0454 use L-0455 (TLSO flex trnk sj-t9 pre ots); for L-0456 use L-0457 (TLSO flex trnk sj-ss pre ots); for L-0466 use L-0467 (TLSO r fram soft pre ots); and for L-0468 use L-0469 (TLSO rig fram pelvic pre ots). For the entire list of codes for custom-fitted devices and the crosswalked codes for OTS orthoses, visit www.oandp.com/link/322.

Q: We recently received several claim denials for spinal orthoses for which we billed. A fellow practitioner told me that claims for lumbar-sacral orthoses (LSOs) are being audited across the country, and I should make sure my paperwork is clear, concise, and complete. What should I include in my checklist for these claims to ensure my paperwork is complete? Are stamped signatures acceptable? I have read your column for the last 12 years and appreciate your feedback.

A: According to Medicare's Local Coverage Determination, spinal orthoses are covered for patients when the brace is prescribed to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the spine or related tissue, or to otherwise support weak and/ or deformed spinal muscles. Spinal orthoses must be billed with the CG modifier, which states the above requirement is met. Your documentation should clearly show the brace is needed for one of the reasons listed above. You should confirm that the prescribing physician's file also documents at least one of the three criteria has been met. To bill using codes for custom fit, you must include documentation of the substantial modifications made to the brace. If substantial modifications have not been made, then the OTS code should be billed. To ensure the device provided has a written coding verification on file, visit the Medicare Pricing, Data Analysis and Coding (PDAC) website, www.dmepdac.com.

If a spinal orthosis is delivered to a beneficiary who is in a hospital or skilled nursing facility for training or fitting and is intended for use at home, it needs to be delivered to the beneficiary within 48 hours of discharge. Stamped signatures are not acceptable.

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.