Original question:
>I have a patient who is a CMS beneficiary. He had been fitted within
>the last year with a fairly involved version of a transradial prosthesis.
Since
>the initial fitting, a number of changes have occurred which will
>require refabrication of the socket to incorporate different control
>mechanism,
etc.
>
>Since the most expensive components are still functional and less than
>a year old I will be reusing most of the parts and refabricate an
>appropriate
>socket. Since CMS does not have a specific code for socket replacement
>in this case, what would be the most appropriate method of billing for
>this procedure?
Responses:
I would bill using the proper base code for the prosthesis, less all the additions you are reusing. Given you will be fitting and fabricating a totally new prosthesis, this is entirely appropriate!
Base code with RP modifier and appropriate fee.
Another prime example of governmental FUBAR. They cause the problem and then are more than willing to dump it in your lap.
Your best bet is to charge the patient what you believe to be a fair price and DO NOT accept the assignment. I would code it with the appropriate transradial code and add the RP and GA modifiers. Don’t even think about transmitting electronically as you will work twice if you do that. Submit copies of the Rx, the doctor’s office notes AND your office notes, then comfortably sit back and wait for the denial.
Then, if you want to keep the patient, help him/her with the appeal, then the fair hearing. In your spare time, a letter of rightous indignation to your congressman, wouldn’t hurt.
If they don’t have a code, I would bill for the base prosthesis and skip the rest. Make it easy on yourself. But since it is fairly recent, lots of doc will be necessary including letter from doctor.
