Monday, May 23, 2022

SNF billing

John Warren

Hello List,

After 5 or so visits to the PalmettoGBA web site(Region C), I found just
what i was looking for. This is a cut a paste from their web site:

Payment for a prosthesis delivered to a patient in a hospital or SNF is
eligible for coverage by the DMERC if:

1. The prosthesis is medically necessary for a patient after discharge from
a hospital or Part A covered SNF stay; and
2. The prosthesis is provided to the patient within two days prior to
discharge to home; and
3. The prosthesis is not needed for inpatient treatment or rehabilitation,
but is left in the room for the patient to take home.

When an initial below knee prosthesis (L5500) or a preparatory below knee
prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or
additions of procedures and components are covered in accordance with the
functional level assessment except for codes L5629, L5638, L5639, L5646,
L5647, L5704, L5785, L5962, and L5980 which will be denied as not medically
necessary. When a below knee preparatory prefabricated prosthesis (L5535) is
provided, prosthetic substitutions and/or additions of procedures are
covered in accordance with the functional level assessment except for codes
L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962 which will be
denied as not medically necessary.

When an above knee initial prosthesis (L5505) or an above knee preparatory
(L5560-L5580, L5590-L5600) prosthesis is provided, prosthetic substitution
and/or additions of procedures and components are covered in accordance with
the functional level assessment except for codes L5610, L5631, L5640, L5642,
L5644, L5648, L5705, L5706, L5964, L5980, and L5710-L5780, L5790-L5795 which
will be denied as not medically necessary. When an above knee preparatory
prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or
additions of procedures and components are covered in accordance with the
functional level assessment except for codes L5624, L5631, L5648, L5651,
L5652, L5705, L5706, L5964, and L5966 which will be denied as not medically
necessary.

Thanks to those of you who resonded to my question.

Sincerely,

John R Warren CP, LP

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