Got FAQs? - April 2019

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By Lisa Lake

Count on Got FAQs? to help answer your toughest billing questions. This month's column addresses a change to billing for bilateral orthoses, and what O&P products must be reviewed by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor. 

Q:  I recently started my own orthotic practice in Oklahoma. I recall reading that Medicare has made a change to billing for bilateral knee braces, but I can't locate the information. What do I need to do to submit my claim to receive reimbursement as quickly as possible? 

A:  On December 6, 2018, Medicare issued an update titled Correct Coding–RT and LT Modifier Usage Change. Effective for claims with dates of service on or after March 1, the right (RT) and left (LT) modifiers must be used when billing two of same items on the same date of service and the items are being used bilaterally. Previous instructions about billing for products to be used bilaterally instructed suppliers to use the RT/LT modifier on the same claim line and indicate two units of service. As of March 1, suppliers must bill each item on separate claim lines using the RT and LT modifiers and one unit of service on each claim line. Claim lines for HCPCS codes that require use of the RT and LT modifiers and are billed without the RT and/or LT modifiers or with the RT/LT on a single claim line will be rejected as incorrect coding. The update can be found at https://bit.ly/2Ce4oVl.

When billing for knee orthoses, suppliers must add the KX modifier to the orthoses and any addition codes only if all the coverage criteria in the current LCD have been met and evidence of such is retained in the provider's file. You will need to ensure that the ICD-10 is coded correctly for the right side and left side. For example, if you are providing a bilateral L-1831, you would bill L-1831 RT KX and the ICD-10 code M24.561 (contracture, right knee) on one line, then bill L-1831 LT KX and the ICD-10 code M24.562 (contracture, left knee) on a separate line. You can view the LCD at https://go.cms.gov/2T9yxjS. 

Q:  I have heard several opinions over the years about whether braces must be approved by Medicare Pricing, Data Analysis and Coding (PDAC). I have been told all products need to be approved, some items do, or that it does not pertain to O&P. I haven't received a definitive answer to my question. Can you provide the correct information, so I can advise my staff how to proceed? When it comes to Medicare, I want to ensure we are doing everything correctly and by the book. 

A:  According to Medicare, a number of items require coding verification review by the PDAC contractor. For orthoses, PDAC requires mandatory submission for only some L-Codes, as follows:

L-1906: Ankle foot orthosis, multiligamentus ankle support, prefabricated, includes fitting and adjustment.

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.

All L-Codes for spinal orthoses, thoracic lumbar sacral orthoses, and lumbar sacral orthoses require coding verification review. For the list of all products requiring coding verification reviews, visit https://bit.ly/2T7DPw8.

Visit the PDAC website to search the Product Classification List on the Durable Medical Equipment Coding System (DMECS) at https://bit.ly/2VSzVEe.

Lisa Lake is an independent medical consultant with over 24 years of experience in the O&P industry, increasing providers' revenue by product recommendation, product and billing knowledge, and contract access assistance. She is a nationally recognized speaker on billing reimbursement and government compliancy. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. Lake can be contacted at llakeusa@gmail.com.