Billing and Collections Q&A

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By Lisa Lake-Salmon
graphic of office activities

Billing for O&P devices and care is complicated. 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 denials for knee orthoses and criteria for providing therapeutic shoes.

Q: We are located in Maine, and I have a question in regard to codes K-0901 (KO single upright pre OTS), L-2385 (Straight knee joint heavy du), L-2395 (Offset knee joint heavy duty), and L-2397 (Suspension sleeve lower ext). I used the RT (right side), LT (left side), and KX (Requirements specified in the medical policy have been met) modifiers, and included the diagnosis code provided, M17.11 (Unilateral primary osteoarthritis, right knee). I received a CO-50 denial (not medically necessary) from Medicare and was informed by a representative the claim was denied for either an incorrect modifier or diagnosis code. How do I get Medicare to reprocess this claim? Any advice you provide is greatly appreciated.

A: According to the information you provided, your claim was denied due to an incorrect ICD-10 diagnosis code. With ICD-10 codes you have to be specific as to the side (RT or LT) or if it is bilateral when selecting the applicable code. Since you provided bilateral orthoses, the ICD-10 code should be M17.0 (Bilateral primary osteoarthritis of knee). The most expeditious way to get your claim reprocessed is to contact Medicare and reopen the claim by phone at 844.687.2656. You will need to have the following information available: 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. A reopening can also be requested by sending a fax to 701.277.2425. For complete information required when sending a fax, visit www.oandp.com/link/332. Reopening forms and checklists can be found at www.oandp.com/link/333. For more information, refer to the supplier manual, Chapter 13: Reopenings and Appeals, at www.oandp.com/link/334.

Q: My father is a new provider of diabetic shoes and inserts in California. He just received his Medicare provider number and wants to ensure we are billing correctly. I have a question on his behalf. I received an e-mail stating the referring physician must see the patient within a certain timeframe so shoes can be provided to the patient and billed to Medicare. What is the exact timeframe and what criteria must a patient meet to qualify for this benefit? If you could provide this information and lead me in the correct direction, I would greatly appreciate that.

A: According to Medicare medical policy, therapeutic shoes are covered if all of the following criteria are met:

  1. The beneficiary has diabetes mellitus.
  2. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions: Previous amputation of the other foot, or part of either foot, or a history of previous foot ulceration of either foot, or a history of pre-ulcerative calluses of either foot, or peripheral neuropathy with evidence of callus formation of either foot, or a foot deformity of either foot, or poor circulation in either foot.
  3. The certifying physician has certified that criteria (1) and (2) are met and that he or she is treating the beneficiary under a comprehensive plan of care for his or her diabetes and that the beneficiary needs diabetic shoes and/or inserts. The certifying physician must have an in-person visit with the beneficiary during which diabetes management is addressed within six months prior to delivery of the shoes and/or inserts and must sign the certification statement on or after the date of the in-person visit and within three months prior to delivery of the shoes and/or inserts.
  4. The supplier must conduct and document an in-person evaluation of the beneficiary.
  5. At the time of in-person delivery to the beneficiary of the items selected, the supplier must conduct an objective assessment of the fit of the shoe and/or inserts and document the results.

For complete coverage information and a checklist to use, visit www.oandp.com/link/335.

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.