Got FAQs: Billing for services to patients prior to discharge, inserts for diabetic shoes, verifying items on the PDAC list

Denials are difficult to identify and time-consuming to appeal. When denials have you at your wit's end, "Got FAQs?" can help you get your billing back on track. This month's column answers your questions about billing for services to patients prior to discharge from a skilled nursing facility or hospital, inserts for diabetic shoes, and verifying items on the PDAC list. Q: Our practitioner provides durable medical equipment (DME) or orthoses to patients at several hospitals and skilled nursing facilities. We have a question regarding billing patients for DME or orthoses provided before they are discharged. We understood that if we provide the service to the patients more than 48 hours before their discharge then we can bill their insurance companies. However, we have been denied payment for several claims with a CO-97 reason code: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. We have changed the location code to either 31 or 32 for skilled nursing facility or nursing facility, respectively, but have not had success in receiving payment for patients we have served in these facilities. The remark code M2 (not paid separately when the patient is an inpatient) has been attached to these denials. Can you clarify this billing situation for us? A : Unfortunately, you were given incorrect information regarding this policy. The Region C Supplier Manual, Chapter 6, Section 13, pages 25-27, covers durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and an inpatient stay ( www.oandp.com/link/180 .) One of the conditions listed that must be met is that "the supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary." The general rule is that the date of service is equal to the date of delivery. However, predischarge delivery of items intended for use upon discharge is considered provided on the date of discharge. In this case, the date of service on the claim should be the date of discharge. Q: When billing for bilateral diabetic shoes (A-5500), what is the maximum amount of inserts we are allowed to bill for? A : The Social Security Act §§1861(s)(12) and 1833(o) provide for coverage of therapeutic shoes and inserts for persons with diabetes mellitus. This is a separate Medicare benefit distinct from the DME or orthotics benefits. Under the therapeutic shoes benefit, beneficiaries are entitled to one pair of shoes and three sets of inserts each calendar year. In order to qualify for coverage under this benefit, the beneficiary must have a diabetes diagnosis. To read the article, visit www.oandp.com/link/181 Q: We are a relatively new practice in Region C, and I was told by a manufacturer's sales representative that not all manufacturers' products will be paid by Medicare. He mentioned that Medicare has a list that verifies if the product and manufacturer is approved. Is this valid and if so, can you tell me how to access the list? A : On August 27, 2012, the Centers for Medicare & Medicaid Services (CMS) Region C contractor, CGS Administrators, issued a news release titled, "Items Requiring Coding Verification Reviews by the PDAC [Pricing, Data Analysis and Coding]." As noted in the local coverage determinations (LCD) and related policy articles that include these codes, claims for these Healthcare Common Procedure Coding System (HCPCS) codes will be denied if the products requiring coding verification review are not listed on the PDAC Product Classification List. The Product Classification List is located on Durable Medical Equipment Coding System (DMECS). To access the DMECS, visit www.oandp.com/link/182 . To read the press release, visit www.oandp.com/link/183 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

Got FAQs: Billing for services to patients prior to discharge, inserts for diabetic shoes, verifying items on the PDAC list

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Bev Combs: Putting Her Best Foot Forward

Successfully Dispensing Foot Orthotics: 12 Tips for Better Outcomes

Hanger Announces 3Q 2012 Results

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