Billing and Collections Q&#038;A

Billing for O&P devices and care is complicated. Count on "Got FAQs?" to help ensure you are using the most current information when preparing your claims. This month's column answers your questions about microprocessor knee L-Codes and the Medicare overpayment appeals process. Q: I am billing my first claim for an Össur POWER KNEE™. I want to verify I am using the correct codes. I have researched the Medicare website, and I am unable to find this information anywhere I looked. A: Effective January 1, the following codes should be used when billing Medicare for an Össur POWER KNEE: L-5856: Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type. L-5859: Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s). L-5828: Addition, endoskeletal knee-shin system single axis, fluid swing and stance phase control. L-5848: Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability. L-5850: Addition, endoskeletal system, above knee or hip disar- ticulation, knee extension assist. Q: I just received my first overpayment demand letter from Medicare, and I am not sure of the specific process and timeline for appeals in order to get my claim paid. I was told Medicare could deny my appeal and I could appeal my claim again. What steps do I need to take to get started? A: There are five levels of appeal for a Medicare claim. You must begin at the first level after receiving an initial determination. Each level after the initial determination has procedural steps that must be taken before an appeal can go to the next level. You have 120 days from the date of receipt of the initial determination or demand letter to file the first appeal, which is also known as a "redetermination." Redeterminations are conducted by Medicare Administrative Contractors (MACs). While you have four months to file your first appeal, you can only avoid a Medicare recoupment action if you do so within 30 days. If you lose your first appeal and decide to appeal the decision, you must file your second appeal within 180 days of receipt of the first redetermination to extend the prohibition on recoupment. Second appeals are called "reconsiderations." Reconsiderations are conducted by Qualified Independent Contractors (QICs). If you lose your second appeal, recoupment will commence 30 days after the second appeal decision is issued. Medicare will recoup the full amount of the audit determination plus interest. This money will not be returned to you unless you prevail in one of the next appeal levels. You have 60 days from receipt of the reconsideration to appeal to the third level, at which an Administrative Law Judge (ALJ) will review your case. If the ALJ process reverses the Medicare overpayment determination, Medicare will refund both principal and interest collected and pay interest on any recouped funds that Medicare took from ongoing Medicare payments. For complete information on how to file all five appeal levels, review the Jurisdiction C Supplier Manual at www.oandp.com/link/192 Lisa Lake-Salmon is the president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact lisa@opedge.com or 800.279.1865 visit www.acc-q-data.com

Billing and Collections Q&A

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