Billing and Collections Q&A

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 replacing knee orthoses and using place of service codes.

leg in brace

Q: We recently had a patient come in to have a knee brace replaced. The brace had been billed with L-1836 (knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf). Is it possible to be paid to provide a replacement brace? Will Medicare deny my claim? How long does a patient need to have an L-1836 orthosis before it can be replaced? Is there a specific way to bill a replacement brace?

A: According to Medicare policy, if a same or similar item is provided during the reasonable useful lifetime (RUL) of an item already in the beneficiary's possession, Medicare will deny it as same/similar. The RUL for the L-1836 is three years. Replacement during the RUL is covered if the item is either lost, stolen, irreparably damaged, or if there is a significant physical change in the patient that prevents continued use of the existing brace. The physician's medical record must indicate the continued need for and use of the item and the reason the current orthosis is not usable. For a replacement to be covered, a new physician's order is needed to reaffirm the medical necessity of the item. The applicable replacement modifier to use is RA (replacement of a durable medical equipment item). In the case of a lost or stolen item, consider including a copy of police records or a patient's written statement. A Local Coverage Determination for Knee Orthoses, including a listing that reflects the RUL of prefabricated knee orthoses, can be accessed at www.oandp.com/link/339.

Q: I work at a physician's office and we recently started providing braces to patients. I have done physician billing for years, but I have only done durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) billing for a few months. I submitted my first batch of claims and they were all denied with reason code CO-58 (Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service). We provided the brace in our office, so we billed with place of service (POS) 11 (office). I do not understand why Medicare would deny these. Can you explain what we are doing incorrectly so our claims can be paid?

A: According to Medicare Region C, POS 11 is not valid for DMEPOS items. For claims submitted to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC), the POS is considered to be the place where the beneficiary will primarily use the DMEPOS item. The following is a list of valid POS codes for submission to the DME MAC:

  • 01 Pharmacy
  • 04 Homeless Shelter
  • 09 Prison/Correctional Facility
  • 12 Home
  • 13 Assisted Living Facility
  • 14 Group Home
  • 16 Temporary Lodging
  • 33 Custodial Care Facility
  • 54 Intermediate Care Facility/Mentally Retarded
  • 55 Residential Substance Abuse Treatment Facility
  • 56 Psychiatric Residential Treatment Center
  • 65 End Stage Renal Disease Treatment Facility (valid POS for Parenteral Nutrition Therapy)

To view a complete list and an explanation for all valid POS codes, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6 - Claim Submission, pg. 21, by visiting www.oandp.com/link/340.

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.