Billing and Collections Q&A

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By Lisa Lake-Salmon

Denials are difficult to identify and time consuming to appeal. When you have questions, count on Got FAQs? to help keep your claims on track. This month's column answers your questions about reopening claims and addition codes that can be billed with knee orthoses.

Q: I recently started working for an O&P office in New Jersey. I received five denials from Medicare for either incorrect modifiers or diagnosis codes. After resubmitting these as corrected claims, Medicare denied them as duplicate claims. How do I get Medicare to reprocess these claims and how do I handle Medicare denials going forward? The practitioner for whom I work suggested I ask you since you are considered an expert in this field. Any advice you provide is greatly appreciated.

A: According to the DME MAC [Durable Medical Equipment Medicare Administrative Contractor] Jurisdiction A Supplier Manual, Chapter 8 - Reopenings and Appeals, if a supplier received a denial for a minor error or omission on an initial submission, then it may be corrected only through the contractor's reopening process. A reopening can be initiated via telephone, in writing, or by fax. To contact DME MAC Jurisdiction A by phone, call 844.687.2656, Monday-Friday, 8 a.m.-4 p.m. ET. You will need to provide the following information: beneficiary's name and Medicare Health Insurance Claim Number (HICN), caller's name and telephone number, supplier's name and Provider Transaction Access Number (PTAN), claim control number, date of service, and reason for the request. Examples of minor errors or omissions include units of service, service dates, Healthcare Common Procedure Coding System (HCPCS) issues, diagnosis codes, modifiers, place of service, and claims incorrectly denied as duplicate charges.

Suppliers should not call the telephone reopening line without first receiving a Medicare Remittance Advice. No action can be taken until a final claim determination has been issued. A reopening can also be requested by sending a fax to 781.741.3914 or 781.741.3842. Be sure to use the Reopening Fax Cover Sheet, which can be accessed at www.oandp.com/link/328. For more information on the five levels of the Medicare appeal process, read Chapter 8 of the supplier manual, which can be accessed at www.oandp.com/link/329.

Q: We are a practice in Texas that provides numerous types of knee braces. The codes we use are K-0901 (KO single upright pre ots), K-0902 (KO double upright pre ots), L-1832 (KO adj jnt pos rigid support), L-1833 (KO adj jnt pos rigid support), and L-1843 (KO single upright custom fit). I submitted a claim for K-0901, L-2492 (knee lift loop drop lock rin), and L-2785 (drop lock retainer each), however L-2492 and L-2785 were denied as they are not paid separately in addition to K-0901. I was told each brace has specific codes we can add and get paid for. Can you provide me with the information I need to bill these, and what additional codes can be billed with knee braces?

A: When billing Medicare for K-0901, K-0902, L-1832, L-1833, and L-1843, the beneficiary must meet the following coverage criteria: Patient has a knee flexion contracture, a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 0 degrees extension or greater by passive range of motion (ROM). A knee extension contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 80 degrees flexion or greater by passive ROM. A contracture is distinguished from the temporary loss of ROM of a joint following injury, surgery, casting, or other immobilization. These braces are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the diagnosis codes that support medical necessity for K-0901, K-0902, L-1832, L-1833, and L-1843. Your records should include documentation of the patient's examination and should state the patient has knee instability and provide an objective description of joint laxity.

The following codes can be billed and paid separately for each of the braces you mentioned:

  • K-0901: L-2385, L-2395, and L-2397
  • K-0902: L-2385, L-2395, L-2397, and L-2795
  • L-1832: L-2397, L-2795, and L-2810
  • L-1833: L-2397, L-2795, and L-2810
  • L-1843: L-2385, L-2395, and L-2397

There are 2,589 International Statistical Classification of Diseases and Related Health Problems - tenth edition (ICD-10) codes listed for these braces. To access the complete medical policy for knee braces and the appropriate ICD-10 codes to use, visit www.oandp.com/link/330.

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.