Got FAQs? - April 2021
April 2021 Issue
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 submitting claims that have miscellaneous and not otherwise specified (NOS) codes, and how to bill for devices patients who are in an SNF.
Q: I work for an O&P facility in Texas. We have recently received denials due to billing for a miscellaneous code. If I am submitting my claim electronically to Medicare, how do I include the product name and description? What code do I use if I am billing for a knee orthosis and spinal braces? I was using L-2999 for both. Any help is always greatly appreciated.
A: According to the Medicare, when you provide a product that does not have an L-Code that describes the exact product you are providing, you need to use a NOS code. There are specific HCPCS codes to use for each group of L-codes. The HCPCS code you will use for a knee orthosis is L-2999(Lower extremity orthoses, not otherwise specified).
The HCPCS code to use for spinal braces is L-1499 (Spinal Orthosis, not otherwise specified). NOS codes should be used for products within the type of code narrative. Spinal brace products have two NOS code options: L-0999 is for an addition to a spinal product, and L-1499 describes a complete spinal product. The remaining codes listed below can be used to describe a complete product not included in the functions or features of another code.
Items billed with any HCPCS code with a narrative description that indicates miscellaneous, not otherewise classified (NOC), unlisted, or non-specified must also include the following information: Description of the item or service, Manufacturer name, Product name and number, Supplier Price List (PL) amount, HCPCS code of related item (if applicable) Miscellaneous.
That information should be included in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form.
HCPCS codes billed without this information will be rejected and will need to be resubmitted with the missing information included.
These are the miscellaneous codes for orthotics: L-0999 (Addition to spinal orthosis, not otherwise specified), L-1499 (Spinal orthosis, not otherwise specified), L-2999 (Lower extremity orthoses, not otherwise specified), L-3649 (Orthopedic shoe, modification, addition or transfer, not otherwise specified) L-3999 (Upper limb orthosis, not otherwise specified). For all NOS O&P codes, visit cgsmedicare.com/jc/pubs/news/2020/10/cope19278.html.
Q: I just started working for an O&P facility. I am extremely puzzled about what we can bill for when a patient is in an SNF or is getting ready to leave one. I was told we could deliver a brace to a patient who was going home after they were discharged from the SNF, but our claim were denied as the patient was in a facility at the time. Can you explain when we can or can't deliver products to a patient in a SNF?
A: According to CMS policy and billing procedures regarding the circumstances under which a supplier can deliver O&P devices to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary's home, the following conditions must be met:
The item is medically necessary for use by the beneficiary in the beneficiary's home.
The item is medically necessary on the date of discharge.
The supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home.
The supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary.
The reason the supplier furnishes the item is not for the purpose of eliminating the facility's responsibility to provide an item that is medically necessary for the beneficiary's use or treatment while the beneficiary is in the facility.
However, pre-discharge delivery of items intended for use upon discharge are considered provided on the date of discharge. The policy can be found at cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf.
There is also a helpful tool you can use to determine if the item is considered under consolidated billing for an SNF. It has information about when an item is payable in the SNF when the Part A stay has ended. For example, L-5301 is payable in a SNF (POS 31 or 32) once the Part A stay has ended. L-5301 is separately payable during a home health episode of care. L-5301 would be separately payable if unrelated to a hospice diagnosis. The tool can be found at med.noridianmedicare.com/web/jddme/claims-appeals/billing-situations/consolidated-billing/consolidated-billing-lookup.
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 email@example.com.