Got FAQs?

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 off-the-shelf orthoses, competitive bidding, and documentation for custom-fabricated knee orthoses. Q: I am a certified orthotist in Jonesboro, Arkansas. I am concerned about reimbursement for back and knee braces due to the competitive bidding program. Which codes are no longer eligible to for Medicare billing? A: On October 27, 2020, the Centers for Medicare & Medicaid Services (CMS) announced the single payment amounts for the off-the-shelf (OTS) back braces and OTS knee braces product categories included in Round 2021 of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Competitive Bidding Program and began awarding contracts in certain competitive bidding areas. Effective January 1, the competitive bidding program went into effect for OTS back and knee braces. Each category has a HCPCS code that is considered the lead item. The competitive bidding price for the lead item will be used to calculate the amount of reimbursement for all other codes listed under the same category. For the OTS back braces the lead code is L-0650. The other back brace codes included in the 2021 competitive bidding program are L-0450, L-0455, L-0457, L-0467, L-0469, L-0621, L-0623, L-0625, L-0628, L-0641, L-0642, L-0643, L-0648, L-0649, L-0651. For the OTS knee braces the lead code is L-1833. The other codes are L-1812, L-1830, L-1836, L-1850, L-1851, L-1852. For the state of Arkansas, the only competitive bidding areas are Little Rock, North Little Rock, and Conway. Only knee braces are impacted by competitive bidding in Arkansas; all other product categories are exempt for now. For the complete listing of all the competitive bidding areas, visit https://bit.ly/3liFb1o. For the complete listing of product categories, visit https://bit.ly/3lf02SV. Q: I recently started working for an O&P practice in Texas. I want to ensure I have all the appropriate documentation in the patients' files. I was told to ask you what needs to be recorded in the patient file to establish why a custom knee brace was ordered. Also what are the addition codes that can be billed with L-1844 and L-1846? A: A custom knee orthosis may be covered as long as the patient's medical records support the need for a custom brace. If the patient is a Medicare beneficiary, you may want to also check if the patient had a same or similar brace. To check for same or similar, visit https://bit.ly/36kS84d on the CGS Medicare Jurisdiction C site. Your documentation for the custom brace should include: duration of patient's condition, the prognosis, and the documented physical characteristic that requires the use of a custom-fabricated orthosis instead of a prefabricated orthosis. Some examples of medical necessity would be deformity of the leg or knee, size of the thigh and calf, or minimal muscle mass upon which to suspend an orthosis. A custom-fabricated knee orthosis with an adjustable flexion and extension joint (L-1844, L-1846) is covered if criteria one and two are met: (1) The coverage criteria for the prefabricated orthosis codes L-1843, L-1845, L-1851, and L-1852 are met; and (2) The general criterion defined above for a custom-fabricated orthosis is met. The addition codes that are eligible for separate payment for L-1844 are L-2385, L-2390, L-2395, L-2397, L-2405, L-2492, L-2755, and L-2785. The addition codes eligible for separate payment for L-1846 are L-2385, L-2390, L-2395, L-2397, L-2405, L-2415, L-2492, L-2755, L-2785, L-2795, and L-2800. For the complete medical policy for knee orthoses and all addition codes that can be billed separately, visit https://go.cms.gov/3ldE0Ag. O&P EDGE Lisa Lake is an independent medical consultant with over 25 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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O&P JOBS

Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

Clinic Manager – Certified Prosthetist Orthotist (CPO) – Rogers, AR

CPO

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EDGE DIRECT

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