Got FAQs? - August 2019

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Count on Got FAQS? to help answer your toughest billing questions. This month's column addresses coding for orthoses, including for noncustom knee braces, delivery to a skilled nursing facility (SNF), and addition codes, and how to bill and document replacement of prosthetic devices. 

Q: For the last five years I have worked for a large firm that had their own billing department that handled all the coding. I have branched out on my own and would like to do my own paperwork and billing. I have several questions about coding for knee braces. I received a request for noncustom dynamic splints and was told by the manufacturer to bill with an E-1810 code. I have never heard of this code. How would it be billed? Also, can you confirm if I can deliver an orthotic device to a patient at a SNF? I know there are some stipulations as to when you can deliver it. Finally, what addition codes can be billed for L-1832, L-1843, and L-1845 braces?

A: E-1810 (dynamic adjustable knee extension/flexion device, includes soft interface material) is billed as a monthly rental to Medicare and the approximate monthly allowable is $121.93. You would bill E-1810 RR KX.

Reimbursement for a knee orthosis delivered to a beneficiary in a hospital or a Part A covered SNF stay will be considered if either the orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and the orthosis is provided to the beneficiary within two days prior to discharge to home; and the orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.

When billing for L-1832, addition codes eligible for separate payment are L-2397, L-2795, and L-2810. When billing for L-1843, addition codes eligible for separate payment are L-2385, L-2395, and L-2397. When billing for L-1845, addition codes eligible for separate payment are L-2385, L-2395, L-2397, and L-2795. For the complete Local Coverage Determination on knee orthoses, visit https://go.cms.gov/2GhBlmG.

Q: I do billing for a prosthetics provider in Puerto Rico. I am relatively new to O&P and have received different answers to my questions about replacement of a prosthetic device, including when it is medically necessary and the documentation I need to have in my file. Do I need to have a signed Assignment of Benefits (AOB) in each patient's file? Your response would be most helpful so we can finally get the correct answer.

A: According to Medicare there are special rules for the replacement of prosthetic devices. A payment may be made for the replacement of prosthetic devices or for the replacement of any part of such devices without regard to continuous use or useful lifetime restrictions if a treating physician/practitioner determines that the replacement device, or replacement part of such a device, is necessary.

Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket, etc.) must be supported by a new order from the treating physician/practitioner and documentation supporting the reason for the replacement. The reason for replacement must be documented by the treating physician/practitioner, either on the order or in the medical record, and must fall under one of the following: A change in the physiological condition of the patient resulting in the need for a replacement. Examples include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary functional need changes; or, an irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or, the condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.

The prosthetist must retain documentation of the prosthesis or prosthetic component replaced, the reason for replacement, and a description of the labor involved, irrespective of the time since the prosthesis was provided to the beneficiary. It is recognized that there are situations where the reason for replacement includes but is not limited to changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very active amputees. To read the complete policy, visit https://go.cms.gov/2YVFcwM.

Payment shall be made to suppliers even without a beneficiary-signed AOB form when the service can only be paid on an assignment-related basis. This includes any mandatory assignment situations and participating supplier situations. When you accept assignment, you must accept Medicare's determination of the approved amount as the full fee for the service(s) rendered. Read more about supplier documentation at https://bit.ly/2XLfpLl.

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.