Got FAQs? - December 2019

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By Lisa Lake

Billing for O&P services 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 same and similar equipment, Medicare denial codes, and documentation requirements for knee orthoses. 

Q:  I recently started working for an O&P company whose billing associate left without any notice. We have since received denials for patients having same or similar equipment. Is there anything I can do to avoid this in the future? Where can I obtain a list of Medicare denial codes to review? Is there a list of all procedure codes and modifiers I can refer to? I greatly appreciate your assistance. 

A:  The list of your claim adjustment reason codes (denial code) and your claim adjustment group codes can be found at http://ww.x12.org/codes/claim-adjustment-reason-codes. To obtain a list of private payers' billing denials and actions, visit www.everestvision.com/medicare-­denial-codes. A list of Level II HCPCS codes can be found at https://bit.ly/34ao5cU, and a list of current modifiers is available at https://bit.ly/2PspEPm.

If a patient received a same or similar item in the past within its reasonable useful lifetime, Medicare will deny the claim as same or similar. Since you are in Texas, you can call the Medicare Interactive Voice Response (IVR) at 866.238.9650. The IVR offers information regarding claim status, pending claims, redetermination status, beneficiary eligibility, and status for same or similar inquiries. You can also register on myCGS (https://cgsmedicare.com/jc/mycgs/index.html) and get instant access to a patient's eligibility and check for same or similar items. When checking for same and similar on the portal during eligibility, be sure to only use the code range of that product category. Noridian also offers a same or similar chart that will assist with code ranges at https://bit.ly/2MZxTRs.

If you find out the patient has received a same or similar item, you should have him or her sign an Advanced Beneficiary Notice of Noncoverage, which can be found at https://go.cms.gov/2JvVJ59. 

Q:  I recently started working for a certified orthotist in Mississippi, and I am new to billing for orthotics. I have billed a few claims for knee orthoses and received denials for incomplete documentation and insufficient medical records. Can you explain for each of the braces I listed what documentation I should have? Any cheat sheets would be greatly appreciated. 

A:  A knee immobilizer without joints (L-1830), or a knee orthosis with adjustable knee joints (L-1832, L-1833), or a knee orthosis with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L-1843, L-1845, L-1851, L-1852) are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Group 2 or 4 Codes in the "ICD-10 Codes that are Covered" section of the LCD-related Policy Article.

Knee orthoses L-1832, L-1833, L-1843, L-1845, L-1851, and L-1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 Codes in the "ICD-10 Codes that are Covered" section of the LCD-related Policy Article.

For codes L-1832, L-1833, L-1843, L-1845, L-1850, L-1851 and L-1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior drawer test).

Claims for L-1832, L-1833, L-1843, L-1845, L-1850, L-1851, or L-1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, the claim will be denied if only pain or a subjective description of joint instability is documented.

For a complete list of ICD-10 codes and coverage information, visit https://go.cms.gov/2BSGkYr. 

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