Billing and Collections Q&A

Billing for O&P devices seems to get more complicated by the day. Count on "Got FAQs?" to help answer your toughest questions. This month's column addresses your questions about billing for replacement knee orthoses and new 2014 L-Codes for AFOs and KAFOs.

Q: We are orthotic providers located in Texas and recently lost our billing person. How can I verify if a patient received a prefabricated knee brace in the past? If we find out the patient did receive one previously, how long must we wait to provide another or similar brace to the patient? What particular information must we submit with the claim? The codes I am interested in are L-1830 (KO immob canvas long pre ots); L-1832 (KO adj jnt pos r sup pre cst); L-1836 (KO rigid w/o joints pre ots); and L-1845 (KO double upright pre cst).

A: Prior to providing L-1830, L-1832, L-1836, and L-1845, call the Jurisdiction C Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) Interactive Voice Response (IVR) at 866.238.9650. When contacting Medicare, you will need to provide your Provider Transaction Access Number (PTAN), your National Provider Identifier (NPI), the last five digits of your tax ID number, and the beneficiary's Medicare ID number, name, and date of birth. If the patient has a knee orthosis that is the same or similar to the device you are providing, you should document what happened to the original equipment and outline the need for a new device. According to Medicare, it is the supplier's responsibility to be aware of the reasonable useful lifetime (RUL) requirement for the item being replaced. If the item has not met its RUL, the claim for a replacement same or similar device may be denied as being not medically reasonable or necessary; in this case, you may have the patient sign an Advance Beneficiary Notice (ABN). If you are replacing the brace prior to Medicare's timeframe for expected use, a new physician order is needed to support medical necessity. Medicare considers the RULs of these braces to be as follows: L-1830, one year; L-1832, two years; L-1836, three years; and L-1845, three years. Replacement during the RUL is covered if the item is lost or irreparably damaged. Replacement for other reasons (including but not limited to irreparable wear) during the device's RUL will be denied as noncovered. You should use the RA modifier if the brace is furnished as a replacement for the same item that has been lost, stolen, or irreparably damaged. The RB modifier should be used if you replace a specific part but not the entire device. Confirm that your documentation and that of the prescribing physician contain all required information to justify the work you are performing.

Q: We are located in Mississippi and provide AFOs and KAFOs. I am new at billing for these services. My boss asked me to confirm with you if there are any new or deleted codes for these devices. Where can I find this information?

A: Three new AFO and KAFO codes were added, effective January 1, 2014. The codes and descriptions are as follows:

L-4361: Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf. L-4387: Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf. L-4397: Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf. To view the 2014 list of new, revised, and discontinued Healthcare Common Procedure Coding System (HCPCS) codes, visit www.oandp.com/link/265 . For additional information on billing for AFOs and KAFOs, visit www.oandp.com/link/266

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 linkEmail('lisa','opedge.com'); or visit www.acc-q-data.com

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