Got FAQs&#8211;December 2021

Billing for O&P services seems to get more complicated by the day. Count on Got FAQs? to help answer your toughest questions. This month’s column addresses Medicare’s same or similar rules for orthotics and updated provider requirements to bill for custom-fabricated and prefabricated orthoses. Q: We are an orthotics provider in Texas. I recently lost my billing staff person, and I am a bit lost. If I provided a brace to Medicare beneficiary in the past or if they received a brace from another provider, how do I know if the patient can get another one? A: When providing a Medicare beneficiary with a brace, you should always verify if the patient had a same or similar item. You can use the CGS Same/Similar Tool ( bit.ly/3q7UjUr ) and enter the HCPCS code of the device. If the patient has had a same or similar brace, a new brace may be covered if the original brace is lost, stolen, or irreparably damaged, or there is a change in the patient’s medical/physiological condition. The medical records should reflect the patient’s change in condition, prognosis, or reason why the previous brace is no longer functional. The referring physician and the supplier’s medical records should reflect the medical necessity. According to the Supplier Manual (Chapter 15, page 124, section 110.2), orthotic devices have a reasonable useful lifetime (RUL) of five years. To read the full policy, visit go.cms.gov/3mIZibY . There are 13 codes that have a RUL from one to three years. For a list of the codes in the knee orthoses policy, visit go.cms.gov/3o1EUSK . Q: I recently moved from California to Texas. I am opening a new facility here and was told I may have to update my information with Medicare to bill for certain orthoses. I never did this in California, so I am assuming Texas has different regulations. Can you shed some light on this and point me in the right direction? A: CMS issued Change Request (CR) 12282 to communicate the addition of HCPCS codes that require the use of a licensed/certified orthotist or prosthetist for furnishing custom-fabricated and prefabricated (custom-fitted) orthoses. This change will apply to dates of service on or after October 1. Claims for items furnished by personnel who are not licensed/certified orthotists or prosthetists by the state in which they practice will be denied. The following states require a licensed/certified orthotist furnish orthotic devices: Alabama, Arkansas, Connecticut, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky, Maryland, Minnesota, Mississippi, Nevada, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, and Washington. In these 21 states where a licensed/certified orthotist provides orthotic devices, suppliers can only bill Medicare for prosthetic devices and certain custom-fabricated orthotics when physicians, pedorthists, physical therapists, occupational therapists, orthotics personnel, and prosthetics personnel furnish them. The following specialties shall bill for Medicare services when state law permits such an entity to furnish a prosthetic or orthotic item: Medical Supply Company with Orthotics Personnel (Specialty Code 51), Medical Supply Company with Prosthetics Personnel (Specialty Code 52), Medical Supply Company with Orthotics and Prosthetics Personnel (Specialty Code 53), Orthotics Personnel (Specialty Code 55), Prosthetics Personnel (Specialty Code 56), Orthotics Personnel, Prosthetics Personnel, and Pedorthists (Specialty Code 57). If a supplier is located in one of the applicable states and wishes to bill Medicare for the prosthetics and custom-fabricated orthotics, it must properly enroll with the national supplier clearinghouse (NSC) to ensure the correct specialty code(s) is on file. In this case, you will need to update your file with the NSC. Change of Information should be submitted on form CMS 855S. To read CR 12282, visit bit.ly/3COEVzF . To update your provider file with the NSC, go to bit.ly/2ZSzZv8 and click on Change of Information. 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.

Got FAQs–December 2021

Regular Orthosis Use Low in CP Patients

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

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

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Got FAQs–December 2021

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Related posts:

Regular Orthosis Use Low in CP Patients

Advocating or Disrupting?

Advocating or Disrupting?

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

Get unlimited access!

EDGE DIRECT

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