Got FAQs? - February 2020

Home > Articles > Got FAQs? - February 2020
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 deductibles, new L-Codes, and delivery of custom fitted and fabricated orthoses.

Q:  I do verification of benefits for a private practice. Since it's the beginning of a new year, I want to ensure we clearly understand the different types of deductibles. How do you know what deductible applies when an individual and family deductible are listed? When checking benefits, the member is listed as the spouse of the policyholder; would the patient be subject to the family deductible or the individual deductible?

Also, are there any new O&P L-Codes that have been added for 2020? As always, I greatly appreciate any feedback you provide.

A:  Family plan policies include more than one member of a family insured under the policy. Family policies can have an embedded deductible or an aggregated deductible. Embedded deductibles are specifically for the member whose eligibility you are verifying when you see a family deductible listed. Policies with aggregated deductibles will show only a family deductible and no individual deductible, and all members of the plan contribute toward the deductible for in or out of network coverage.

Family health insurance plans with an embedded deductible include both an individual deductible and a family deductible. With individual deductibles, each policy member has a personal deductible, and once that deductible has been met, the benefits will kick in for that member only, and all individual deductibles apply to the family deductible. Once the family deductible is met, all policy members will no longer have an individual deductible whether or not each individual met the deductible threshold.

Only two L-codes were added for 2020: L-2006 (knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated) and L-8033 (nipple prosthesis, custom fabricated, reusable).

Q:  I work for an orthotist in Florida, and we have several patients who live here for half the year and half in New Jersey. Two of our Medicare patients returned to New Jersey before picking up their completed and fitted custom braces. Can we mail the braces, and if so, what documentation would we need if we send them by UPS or FedEx?

A:  According to Medicare guidelines you can deliver products via a shipping or delivery service directly to a beneficiary. If you utilize a shipping service or mail order, the proof of delivery (POD) documentation must be a complete record tracking the item(s) from you to the beneficiary. An example of acceptable POD would include both your detailed shipping invoice and the delivery service's tracking information. Your record must be linked to the delivery service record by some clear method, such as the delivery service's package identification number or your invoice number for the package sent to the beneficiary.

The POD document must include the beneficiary's name, delivery address, the delivery service's package identification number, your invoice number or an alternative method that links your delivery documents with the delivery service's records, and a description of the item(s) being delivered. The description can be either a narrative description (e.g., knee orthoses w/adj jt rot control molded), an HCPCS code, the long description of a HCPCS code (knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), quantity delivered, and date delivered. You may use the shipping date as the date of service (DOS). The shipping date is defined as the date the delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation. You may use the date of delivery as the DOS on the claim. To read the complete policy on supplier proof of delivery documentation requirements, visit www.cgsmedicare.com/jc/pubs/pdf/chpt3.pdf.

Lisa Lake is an independent medical consultant with over 25 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.