Friday, May 20, 2022

Responses to: Region C coding…again

Gary Lamb

Thanks everyone, misery loves company…
The replies:

I just was denied payment for a pair of custom-made shoes since my patient
went to an O&P shop in another town and was fit with a pair of off-the-shelf
extra depth shoes five months prior. I personally don’t consider these two
different types of shoes similiar. Yes they are both shoes in the same
manner that apples and oranges are both fruit.
Soldier on
The same here. We have a 4 inch thick binder of Medicare denials under

appeal. Most for AFO with previous cast boot fittings by EBI stock & bill.

Get this. Recently I had a bilateral BE that needed his terminal devices
retreaded-normal every 3 month deal. Hosmer will only retread them once
before the TD needs to be replaced. I sent in the claim as a “99” code and
Medicare region C reduced the payment by over $130- $30. below my cost. for
some unknown reason. I called to ask why and they checked with the person
authorizing the payment. They are now reopening the case and are going to
send it to “pricing” whatever that is. So get ready, now they’re probably
only going to allow the price the manufacturer charges. I guess we’re going
to be reduced to a labor only deal soon.
I enjoyed reading your post this morning and printed it for my office staff
to read. You are certainly not alone with your frustration. The example
you cite has been experienced by our office on multiple occasions. We have
attempted to institute internal policies to protect us from a recurrence of
this scenario, but despite continuing efforts on our part, we are not always
able to determine if a ” same or similar” device has been provided in the
past. Perhaps it is simply a case of the patient’s memory not being
reliable (either intentionally or unintentionally) or more likely, confusion
on the part of the patient. As we struggle with this unfolding Medicare
policy I am aware of the confusion on the part of our patients. If I am
having difficulty unraveling Medicare’s convoluted policy, how can I expect
my patients to understand and always provide the most accurate background
information. I continually try to look at this situation from Medicare’s
prospective, and I try to leave emotions out of this process. Trying to be
as objective is possible I still must conclude that our industry (at least
in Region C) is being treated with an extraordinary degree of unfairness. I
recently contacted Keith Crownover, CPO from Oklahoma City who has discussed
putting together a class action lawsuit. Initially, I dismissed this idea,
but out of sheer frustration I have decided to provide him with examples of
our experiences of heavy-handed, inappropriate, inconsistent and erroneous
application of policy by Medicare. I have begun to contribute to our PAC
fund, and I suppose it will be necessary for me to personally begin to play
an active role in this process.
I would be curious to hear from you any suggestions or thoughts on what we
can do as a group to appeal to Medicare to seek relief from this repressive
atmosphere that has developed. Our patients are suffering and I suspect
that many small orthotic and prosthetic businesses may eventually be at risk
for closing if we do not receive relief from Medicare’s current oppressive
Wouldn’t the operative word here be “custom”?


I have a case in review for bilateral AFO’s. Medicare originally paid for
the dorsi assist addition and limited motion without paying the base code.
We inquired about this and Medicare asked for their money back on the
additions and put all of the codes on review. We submitted all
documentation including doctor’s detailed notes stating the patient’s
neuropathy, foot drop, and test to confirm this. Medicare acknowledges the
documentation but says we did not justify a custom orthoses over an
off-the-shelf. How many thermoplastic articulating AFO’s OTS have you fit
in your career? I bet close to none. The joint spacing and height besides
the overall fit can not be accomplished by an off the shelf. This should be
self evident.

In this case these are the patient’s first pair of orthoses. The patient
and his wife are upset about this and have personally written Medicare.
They would like to be here for the in person hearing. When we told the
Medicare review person that the patient wanted to be here for the hearing he
wanted to make it clear that patient being there would have no impact on the
case. He said that he does not know about orthotics and only the
documentation will be considered. He was trying to discourage me from
having the patient present. If Medicare is sending people out for hearings
and they do not have the ability to visually determine if the orthosis in
medically necessary then what good are they? Medicare is frauding us and
the patient.

Fortunately, I know the doctor well and we will have plenty of documentation
to show that a trip to my office will be a gross missue of our tax dollars.

This is a mess, but I hope you appealled it. I would go as far as requesting
an in person hearing. Yes,

time may be involved, but I’ve often seen a reversal of denial and payment
before an in person appeal

hearing is scheduled by them. I agree about hoping to meet payroll. It’s
really frustrating when you have

literally thousands of dollars out in AR and are struggling to pay bills. I
love this job.


Gary A. Lamb LPO, CO, FAAOP
Comprehensive Orthotic-Prosthetic Enterprises (C.O.P.E.)
1742 Hickory St.
Abilene, Texas 79601

[email protected]


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