<img style="float: right; margin-left: 3px;" src="https://opedge.com/Content/OldArticles/images/2009-02_09/faq.jpg" alt="Lisa Lake-Salmon" /> <b><i>Denials are difficult to identify and time consuming to appeal. With competitive bidding, mandatory accreditation, aging technology, and increased billing errors, running an O&P facility gets more complicated each year. This month's column addresses your questions about documentation for lower-limb prostheses, co-pays, and socket replacements.</i></b> <b style="color: #ce1429; font-size: 150%;"><span style="font-size: 14pt;">Q</span>:</b> I am a new prosthetics provider in Region D. I am seeing my first transtibial patient and would like to make sure I have all the clinical documentation I am required to keep in the patient's chart. Do you know where I can find a list of this nature? <span style="font-size: 14pt;"><b>A:</b> </span>Medicare Region D publishes a documentation checklist for lower-limb prostheses. To view a complete list of documentation requirements for a patient's file, visit <a href="https://opedge.dev/3230" target="_blank" rel="noopener noreferrer">www.noridianmedicare.com/dme/coverage/docs/checklists/lower_limb_prostheses.pdf</a> <span style="font-size: 14pt;"><b style="color: #ce1429;">Q:</b></span>O&P devices include the professional-service reimbursement within the base billing codes; when is an O&P provider entitled to collect the $20 co-pay? As an example: a patient with PPO coverage presents for a custom scoliosis brace. The policy specifies a $20 office-visit co-pay, $500 deductible, and 20 percent co-insurance with a $5,000 out-of-pocket maximum annual expense. The patient has only met $300 of his deductible following a doctor's visit and x-ray. <span style="font-size: 14pt;"><b>A:</b></span> There are several considerations to take into account before answering this question. Does the patient's $500 deductible include O&P services? Does the patient's plan have a yearly maximum for prosthetics and orthotics? If so, you would first need to collect the remaining portion of the patient's deductible before any co-pays would apply. To cover all the possible questions, you may want to ask the patient's insurance company. Initially, you should have a standard insurance verification form that your billing staff uses. Most insurance carriers have websites you may use to verify benefits and coverage. If you need a sample insurance-verification form, please contact me directly at <script language="javascript">linkEmail('lsalmon','acc-q-data.com');</script> <b style="color: #ce1429; font-size: 150%;"><span style="font-size: 14pt;">Q</span>:</b> Does Medicare reimburse providers for socket replacements? If so, what documentation do I need to provide for this, and how many sockets does Medicare allow? <p<span style="font-size: 14pt;"><b>A:</b></span> Medicare will consider socket replacements medically necessary as long as there is sufficient documentation in the patient's file for functional and/or physiological need, such as changes in the residual limb, weight gain or weight loss, etc. More than two test (diagnostic) sockets—L-5618 through L-5628—for an individual prosthesis are considered not medically necessary unless there is adequate documentation in the patient's medical record that justifies the need for more than two. No more than two of the same socket inserts—L-5654 through L-5665, L-5673, L-5679, L-5681, and L-5683—are allowed for an individual prosthesis at the same time. <i>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,</i> The O&P EDGE <i>is not responsible for errors. For more information, contact <script language="javascript">linkEmail('lisa','opedge.com');</script> or visit <a href="https://opedge.dev/3210" target="_blank" rel="noopener noreferrer">www.acc-q-data.com</a></i>
