Billing and Collections Q&#038;A

When you need help with your toughest billing questions, count on "Got FAQs?" to provide you with the information you need to help keep your billing on track. This month's column tackles your questions about criteria for addition codes with microprocessor-controlled knees and documentation for footwear for beneficiaries with diabetes. Q: My husband, a certified prosthetist, and I just opened our own facility in Alabama, and I am filing his Medicare claims. We received denials on two separate claims for electronic or microprocessor knees. One claim was coded 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)); and L-7360 (six volt battery, each). The other claim was coded L-5857 (addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type); L-5859; and L-7360. Both patients have a K3 functional level. On one claim Medicare paid L-5856 and L-5859, and on the other claim it denied L-5859. On both patients it denied L-7360. What am I missing? A: L-5859 is only covered when the beneficiary meets all of the following criteria: has a microprocessor swing-and-stance phase type (L-5856) electronic knee; is K3 level only; weight is greater than 110 pounds and less than 275 pounds; has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3-level function with the use of a microprocessor-controlled knee alone; is able to make use of a product that requires daily charging; and is able to understand and respond to error alerts and alarms indicating problems with the function of the unit. L-5856 can only be used to bill for an additional microprocessor-control feature swing-and-stance phase control, while L-5857 covers swing phase only control. L-7360 for the batteries is included in the base codes and is not paid separately. You can find this information in the Local Coverage Determination for Lower Limb Prostheses at www.oandp.com/link/273 Q: Our office is in Mississippi, and we just received our Medicare provider number. We have several prescriptions to provide A-5500 (for diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe) and A-5513 (for diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16-inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each). Can you provide me with a list of what documentation Medicare requires in our patients' files? We also need clarification on the requirements for the in-person visit. A: The Centers for Medicare & Medicaid Services (CMS) Supplier Standards (42 CFR 424.57) requires that suppliers of therapeutic shoes for persons with diabetes perform an in-person visit with the beneficiary for the purpose of determining fit. The supplier must document an objective assessment of the shoes regarding fit. This objective assessment by the supplier is a critical component of the delivery process. You also need an attestation from the beneficiary about the quality of the shoe and/or insert fit. The person performing the in-person visit should be a skilled professional with training in the proper assessment of fit and the relationship of the shoe and/or insert to correction of the underlying foot condition. You can view this information, including a documentation checklist for therapeutic shoes, in an article dated February 27, at www.oandp.com/link/274 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 visit www.acc-q-data.com

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