Got FAQs? – June 2021

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 billing for off-
the-shelf (OTS) braces and claim denials for minor errors.

Q: I am a physical therapist working for an orthopedic physician in Georgia. I have just started working here, and I provide knee braces to my patients if needed. The physician will also provide braces to his patients. We have been approved to be Medicare DMEPOS suppliers and are aware of the competitive bidding program, but we are not sure how it applies to a physician or physical therapist. Are we able to provide these braces even if we did not win any of the competitive bids?

A: According to the Medicare Learning Network (MLN) fact sheet, physicians and other treating practition­ers (physician assistants, nurse practitioners, and clinical nurse specialists) and physical therapists and occupational therapists are exceptions to the competitive bidding program. If you are a DMEPOS-approved supplier, as a physician, other treating practitioner, or physical or occupational therapist, you have the option to bill Medicare as long as you furnish the brace to your patient as part of your professional service. The OTS back brace or OTS knee brace must be billed using the DMEPOS billing number that is assigned to the physician, treating practitioner, or therapist.

When billing Medicare for an OTS knee or back brace as a non-contract supplier, physicians should use the modifier KV, and physical therapists and occupational therapists should use the modifier J5, along with any appropriate modifier for that brace. The claim billed for either the OTS back brace or OTS knee brace must have the same date of service as the professional service office visit or physical or occupational therapy service billed to the Part A/Part B MAC. To find out if your patient is in a competitive bid area, visit dmecompetitivebid.com. To read the MLN fact sheet, visit go.cms.gov/3uAHIIZ.

Q: I recently took over the billing for my husband’s practice. I have received denials for invalid ICD-10 codes and missing modifiers. We are providing prefabricated braces L-1851 and L-1852 and custom-fabricated L-1844. What is the documentation we need to have to bill these?

A: If you received a denial for claim that had a minor error or omission, you can request a reopening either online at mycgsportal.com/mycgs or by calling 866-813-7878. Examples of minor errors or omissions include mathematical or computational mistakes, ICD-10 codes, inaccurate data entry, incorrect data items such as provider number, use of a modifier, or date of service.

To change, add, or remove modifiers KX, GA, GZ, and GY, claims must be appealed through redeterminations with supporting documentation. Jurisdiction C suppliers may submit their redetermination request form at bit.ly/3troiVk. You can also utilize Medicare’s claim denial resolution tool at bit.ly/3eooHn2.

L-1851 and L-1852 require your documentation show that the patient has had a recent injury to, or a surgical procedure on, the knee(s). In addition, the medical necessity needs to be supported by one of the ICD-10 codes in Group 2 or 4 codes located in the Knee Orthoses Local Coverage Determination (LCD) (L-33318).  Ambulatory and knee instability codes require your documentation show that the patient is ambulatory and has knee instability. Your examination of the patient and your objective description of joint laxity (such as varus/valgus instability, anterior/posterior Drawer test) are required. In addition, the medical necessity needs to be supported by one of the Group 4 ICD-10 codes listed in the Knee Orthoses LCD (L-33318). For L-1844, custom-fabricated knee orthoses, the same basic coverage criteria applies as the same type of prefabricated knee orthosis. However, there must also be documentation in your records to medically describe why your patient needs a custom-fabricated device instead of a prefabricated knee orthosis. Examples of situations that meet the criterion for a custom-fabricated knee orthosis include, but are not limited to, deformity of the leg or knee, size of the thigh and calf, and minimal muscle mass upon which to suspend an orthosis. To read the Medicare LCD for the complete coverage on knee orthoses, visit go.cms.gov/33mnzKB.

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 [email protected].