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Included below is the OP/DME portion of the article from Advance for Rehab Directors.
John Brinkmann, CPO
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Vol. 13 •Issue 4 • Page 51
Money Makers
Among techniques to increase reimbursement, learn to bill properly for O&P.
By Rick Gawenda, PT
In health care, we need to scour .opportunities to increase reimbursement. Too often, however, we miss chances to capture money, particularly in billing for orthotics and prosthetics (O&P) and using modifier -59 for the Correct Coding Initiative (CCI) edits.
When it comes to O&P, many of us want to provide these services to our patients, only to be told we can’t bill for them because we don’t have a Durable Medical Equipment (DME) license. Depending on your practice setting, this misconception could be costing you thousands of dollars.
Let’s clear up the confusion. DME doesn’t include orthotics and prosthetics. They are two separate and distinct categories and, therefore, are billed differently, depending .on your practice setting. DME is billed through your Durable Medical Equipment Regional Carrier (DMERC), using the appropriate Healthcare Common Procedure Coding System (HCPCS) Level II codes. Orthotics and prosthetics are also billed using HCPCS Level II codes.
L codes, as they’re called, are HCPCS Level II codes and include orthotic and prosthetic procedures and devices, as well as scoliosis equipment, orthopedic shoes and prosthetic implants. Orthotic procedures HCPCS codes range from L0000-L4999 and prosthetic procedures from L5000-L9999.
Examples of DME are walkers, wheelchairs and hospital beds. Orthotics and prosthetics include pre-fabricated or custom-fabricated splints. They also include prostheses for the upper and lower extremity, as well as spinal orthoses, such as a thoracic-lumbar-sacral orthosis.
Complicating matters is that providers often don’t understand the billing regulations for DME and O&P. Each practice setting has different regulations for billing DME, O&P and supplies. These regulations determine who you’ll bill and the forms you’ll need to do so.
Who Needs a DME License?
Hospital outpatient departments don’t need a DME license to bill their Fiscal Intermediary (FI) directly on Form HCFA-1450 (UB92) for O&P. They need to bill using revenue code 274, along with the appropriate HCPCS code for the orthotic or prosthetic device. The FI will pay for O&P devices on a lump-sum cash basis, using the lesser of the Medicare fee schedule amount or the actual charge.
Hospital outpatient departments, however, can’t bill their FI for DME. They would need to have a DME license and submit their bill on Form HCFA-1500 to their DMERC.
Home health agencies don’t need a DME license to bill for O&P. Instead, they bill their Regional Home Health Intermediary directly on Form HCFA-1450. HHAs bill for O&P devices under revenue code 274, along with the appropriate HCPCS code representing the orthotic or prosthetic device. They’re paid in the same manner as hospital outpatient departments.
Private practices need a DME license to bill for DME, O&P and supplies for part B therapy services. To do so, they need to contact the National Supplier Clearinghouse (NSC). This is the national entity contracted by the Centers for Medicare and Medicaid Services (CMS) that issues supplier authorization numbers through Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies. The NSC will give providers information about the application and other supporting documents.
Once practitioners complete the application and have obtained the supporting documentation, they should submit the information to the NSC. The application form—CMS 855S—can be found at www.cms.gov/forms. Practitioners would then need to submit their bills to their respective DMERC on Form HCFA-1500. They’d be paid in the same manner as hospital outpatient departments.
DMERCs establish the base fee schedule for all DME, O&P and supplies, except implanted DME and implanted prosthetic devices. The Health Care Finance Committee Bureau of Data Management and Strategy calculates the regional fee schedules for O&P.
Knowing how to bill for orthotics and prosthetics can save your facility money. So can using modifier -59….
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