Fellow Orthotist-
So, the sounds of things is….You can use ultra flex for AFO’s because they have assigned codes. Upper extremity, using the L3999 even if you justify it with “similar to lower extremity code L_ _ _ _” will likely not get paid. You can’t typically even submit misc codes to Medicaid/VA premiere so that is not an option. Submitting L3999 codes even with a similar lower extremity code to Medicare will likely not be covered and seems people within the orthotic community are just staying away from this, getting an ABN signed with a GA modifier on codes. Maybe if Ultraflex would go to bat for us and fight for UE codes for these devices, we would be in better shape. Private insurance is a different thing because you can get pre-auth, though not guaranteeing coverage.
I recently did bilateral UE ultraflex devices on a patient with Medicare primary, private secondary. I coded it exactly how ultraflex suggests. We are going to see what happens with payment from Medicare on these L3999’s but at this point with a device that has as much value and has a place in our field, why are they not getting codes for this device.
Expensive way to find out whether we will get paid or not. Just letting you know, be aware, call ultraflex, high encourage them to get codes that we can actually use.
Let me know if I am missing something here but as of now, we likely will not be able to provide UE ultraflex devices for Medicare and Medicaid patients. Below are responses I received.
Sharidy MacCord, CPO
RESPONSES
They are a great product, but coverage is HORRIBLE! In my experience Ultraflex does not seem to understand the fight that we are in to prove medical necessity. They need to focus on their coding and stop leaving practitioners hanging at the time of billing. Their products are specialized enough to warrant the attention of PDAC but it does not seem to be a priority for Ultraflex. Just my opinion.
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The ultra flex upper extremity orthoses that you are using are they the
custom or off the shelf? If they are custom then you should be billing it
using as many same and similar codes as possible. If you are billing it as
off the shelf for example the elbow orthosis then you may get some payment
from insurance but it will not cover the cost let alone a profit. In those
cases we’ve told the patient upfront the cost to them, have then sign an ABN
and collect upfront then bill Medicare as a non assigned claim. With some
private insurances you can preauthorize but not many using the L3999.
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Great question. I’ve avoided these and all 999 codes with medicare & medicaid. It’s too much hassle and stress over reimbursement. Private insurance is different.
The devices are great but I can’t use the on the population that really needs them due to insurance.
Let me know the responses please.
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We did quite a few early on and have not gotten paid for those codes yet. These claims are over 8 months old. Still fighting, but it is not looking real good. We are very aggressive in our claims and there is not much we don’t get paid for. We have gotten all the info from their reimbursement team, but still no success. We are not going to use any of their devices with the L3999 codes until we resolve the ones we still have outstanding. I do not want to discourage you, just giving you my experience. I had one come up Monday that I would not allow to order because of our experience with payers.
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Sharidy MacCord, CPO
Virginia Prosthetics and Orthotics
Roanoke Office (540)366-8287
Lynchburg Office (434) 455-2930
[email protected]
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