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 spinal orthoses and detailed written orders for knee orthoses. Q: I have been an orthotist for ten years and always worked as an employee. I have decided to branch out on my own and need assistance with billing. I have heard there is different coding for off-the-shelf (OTS) spinal orthoses as opposed to custom-fitted orthoses. I have included a list of the OTS orthoses. Can you provide me with the codes for the custom-fitted braces for the corresponding OTS devices? What documentation do I need to provide for these? Is there specific wording for either type of brace? Where can I obtain information on how to bill these correctly, including any quick reference sheets? A: Both OTS and custom-fitted items are considered prefabricated braces for Medicare coding purposes. Correct coding of a spinal orthosis is dependent upon whether there is a need for "minimal self-adjustment" or substantial modifications during the final fitting at the time of delivery. The brace is considered OTS and should be coded as such when minimal self-adjustment was provided at final delivery; the brace is considered custom fitted when substantial modifications were made. I would advise that if you are providing a custom brace, all modifications should be documented clearly and concisely in your patient records. For example, the brace has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific beneficiary by a certified orthotist or an individual with equivalent expertise (i.e., physician, treating practitioner, physical therapist, or occupational therapist). The referring physician's letter of medical necessity should state "custom fabricated" and the patient's medical records should also state why he or she needed a custom brace. Codes that fall into this category are: L-0641 (OTS) L-0626 (custom fit), L-0642 (OTS) L-0627 (custom fit), L-0643 (OTS) L-0630 (custom fit), L-0648 (OTS) L-0631 (custom fit), L-0650 (OTS) L-0637 (custom fit), L-0649 (OTS) L-0633 (custom fit), L-0457 (OTS) L-0456 (custom fit). To read a complete local coverage determination on all spine and back braces, visit Medicare's website at https://bit.ly/2KIa8tt . Q: I am a physician who has recently started to directly supply my patients with knee braces. If I am the supplier and the physician, do I write the detailed written order? Can you also advise all codes I can bill for L-1832, L-1833, L-1843, and L-1845? How long does the patient have to wait before receiving a new brace if he or she previously had one, provided that it is medically necessary? A: According to Medicare, "If you fulfill all the elements required on an order within the medical records, where the physician (prescriber) and the supplier are the same, then those medical records can be considered as the detailed written order. All the elements should be clearly documented on what the physician is ordering. Physicians are encouraged to document a separate detailed written order to ensure the required elements are documented." The reasonable useful lifetime (RUL) according to Medicare and the addition codes payable separately for each brace are as follows: L-1832: (RUL 2 years), addition codes L-2397, L-2795, L-2810; L-1833 (RUL 2 years) addition codes, L-2397, L-2795, L-2810; L-1843 (RUL 3 years), addition codes L-2385, L-2395, L-2397; L-1845 (RUL 3 years), addition codes L-2385, L-2395, L-2397, L-2795. Before providing a knee brace to a Medicare patient you should always verify whether the patient received a same or similar brace within the RUL for each brace. To review the medical policy, visit https://bit.ly/2zLmoVj. Lisa Lake is an independent medical consultant with over 24 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 llakeusa@gmail.com.

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