Billing and Collections Q&A

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 patient file documentation and when to use the CG modifier for spinal orthoses, and which place of service code to use when filing claims with Wellmark Blue Cross and Blue Shield of Iowa and its affiliate and subsidiary companies. Q: My husband recently opened his own facility in Utah, and I am doing his billing. Can you advise us what documentation we must have in our patient file to identify whether an orthosis is custom or prefabricated? I also need to know which L-Codes to use with the CG modifier. Any help is greatly appreciated. A: The distinguishing factor between a custom-fitted and prefabricated orthosis is the need for "minimal self-adjustment" at the time of fitting by the beneficiary, caretaker for the beneficiary, or supplier. This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training. Items requiring minimal self-adjustment are coded as off-the-shelf (OTS) orthoses. Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. For custom-fabricated spinal orthoses (L-0452, L-0480, L-0482, L-0484, L-0486, L-0629, L-0632, L-0634, L-0636, L-0638, and L-0640), there must be detailed documentation in the treating physician's records to support the medical necessity of a custom-fabricated rather than a prefabricated orthosis. This information will be corroborated by the functional evaluation in the orthotist's records. The CG modifier (policy criteria applied) must be added to a spinal orthosis (L-0450, L-0454, L-0621, L-0625, and L-0628) only if it is made primarily of nonelastic material (e.g., canvas, cotton, or nylon) or has a rigid posterior panel. When providing these items, a supplier must provide the product that is specified by the ordering physician; the physician must specify the type of orthosis and method of fitting and/or fabrication (OTS or custom fitted). Be sure that the medical record justifies the need for the type of orthosis and method of fitting, and that you have detailed documentation in your records that justifies the code selected. To read the medical policy coverage in its entirety, visit www.oandp.com/link/305 . Q: The billing company I use has told me that place of service (POS) code 11 (Office) should be used on the Centers for Medicare & Medicaid Services (CMS) 1500 claim form for Wellmark Blue Cross and Blue Shield of Iowa, but for Medicare we are to use POS code 12 (Home). That does not make sense to me. I have always been told by my colleagues that the POS should always be 12 as this is where the patient is going to use the device. Please help; I need your advice. A: The Wellmark Home Medical Equipment, Orthotics and Prostheses Guide , which was updated February 2015, applies to all patients covered under and all claims filed with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa. According to information in that guide, Wellmark will follow the coding guideline used by CMS when processing claims for orthotics and prosthetics. POS 11 will no longer be accepted as a place of service. Instead, use one of the following POS codes: 01 (Pharmacy); 12 (Home); 13 (Assisted Living Facility); 14 (Group Home); 16 (Temporary Lodging); 32 (Nursing Facility); 33 (Custodial Care Facility); 55 (Residential Substance Abuse Treatment Facility). To access the Wellmark Home Medical Equipment, Orthotics and Prostheses Guide, visit www.oandp.com/link/306 . 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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