Only L1858 should be used for all Custom KOs made and ANY company, except L1844 can be used for Generation II. NO ADD ON CODES should be used as all add ons are inclusive in the base codes. You can add on L2755 to the Generation II orthoses as the original L code had polyethylene cuffs. The only way you could us the other add on codes, if you manufactured the orthosis in your own laboratory. Any changes will need to come from the KO manufacturers by obtaining new codes from the SADMERC. What you are missing is the original code defined a specific product and that still determines the add on potential. Hope this helps. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, You are correct in the inclusion of these ‘add-ons’ for the manufactured items. It seems to me that there should be no difference between the items made in your lab or someone else’s lab. Unfortunately, the reps are not doing this for our benefit…They make the same commission for a sale whether I fit it or they fit it. I cannot and will not fit a Gen II Custom for the base code; I will lose money on that deal. If you are interested in a race to the bottom, then have at it. I strongly recommend that you take the AOPA Coding Seminar to clear up these issues. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
First KUDOS to you for fighting for what is rightfully yours. Insurance companies have way too much power over what we bill for and what we don’t. You are justified in billing for those add on codes as per the description of each code. DJ and CTi get away with base billing because they have no”other ” costs involved. They have no middle man. Insurance companies should be checking out their (DJ CTi) credentials and asking for copies of accreditation, trading license, certification for O & P, and liability insurance forms. They ask us as providers for these items. Ours is not an easy fight if we are not careful we can loose referrals. It is easy to say lets Boycott DJ and CTi but Everyone would have to agree and that will probably never happen. Maybe our industry organizations ( AOPA, IAOP,etc.) could help by not allowing them at conventions but that would mean loss of revenue for them. What your doing is right and I hope you continue. I wish you luck, I have been there myself and sometimes the outcome has been favorable. I do know that HCFA is currently working on new regs for O & P and maybe by the end of the year we will not have to be in direct competition with manufacturers.Good Luck, ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hi Mr. Madden.I am currently going through the exact scenario that you are describing. My case was with a DJ knee orthosis regarding the use of the polycentric knee joint code. I was able to obtain a letter from Don Joy that stated that the orthosis is manufactured with polycentric joints. (Don Joy only recommends the base code.) I have had many discussions with Don Joy asking them to either recommend all of the applicable codes, or to make no recommendations at all, leave the coding to the responsible practitioner. I was told that this has been the source of headaches for them, and that they are considering not recommending any codes. At this point, the “fraud and abuse” person with the insurance co has said that I was right with my coding and to proceed with billing the patient for his portion. But my problem does not end here. The patient does not understand how “one knee orthosis can possibly have four joints”, and refuses to pay his portion. If I write off this balance, it is like admitting guilt. BUT, he is threatening the insurance co with the insurance commissioner, and I enjoy a good relationship with this insurance co. I have already lost a lot of $$ with administrative costs fighting this, and I don’t think it’s over yet. Worse,from what you say, I’m now afraid that I will be fighting the same battle with more insurance companies.My best thought is that it’s time to provide knee orthoses that come from manufacturers who understand how coding works, and will support us in our battles for reimbursement. Using products from DJ and CTi and others,who compete with us by selling directly and billing their products using incomplete coding, just continues to hurt us. I am now afraid to use anything but the manufacturers recommended codes, and therefore am in the process of selecting new products based on some of these issues (as long as I can find equal quality). I am interested to know if you think that we can educate the third party payors or if you think that they all will “play dumb” in order to get away with paying less? How do you plan to deal with the ones that we cannot educate? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike, First if your coding for a specifically defined orthosis from the L-codes concerning specific knee orthoses then the insurance company happens to be correct in assuming you are unbundling the parts. For example you cannotby a CTI orthosis with a different knee joint than polycentric so you can’t break out the joints seperately. On the other hand if the orthosis is being made to specification like a Townsend then you are able to bill for the specific requirements of the orthosis. In the case of companies direct billing using only base codes, you will almost never win. The charges to you do not allow you to provide the brace and service for the reimbursment rate. Unless you hae a really good relationship with a rep your fighting an up hill battle. If you have a good relationship with your doctors have them go to a completely generic prescription. This would allow you to provide the orthosis with all of the add ons prescribed. If your doctors are not willing to change then try discussing it with the companies. Finally be careful when attempting to unbundle codes especially with orthoses that are described in the L-codes that’s where you walk the fraud and abuse line.GOOD LUCK WITH YOUR QUEST. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike,This is just one more example of the field getting away from the practitioners. It is extremely frustrating. We are getting pulled into ‘tug of wars’ in many areas and my simplest strategy has been to let go of the rope. I just won’t play around with them. The way I see it, if they want to pay for a base code item, I’ll give them a base code product. I’ll pay less and they’ll pay less. If they want bells and whistles, they are just going to have to pay for it. Even if the product comes with the extras, I end up paying a higher price for the upgraded item than I would for base code item. We are not doing ourselves or the industry any favors by caving. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I have positioned myself as a specialist. I go the extra mile and make sure everything I do is proper and effective. My patients, my doctors and I know it. If the insurance companies don’t see it that way, I tell them to go to another facility. If the other facility wants to do it at a cut rate price, they’ll end up paying for it initially but, inevitably, we all end up paying for it. My stance was difficult at first, but I want to assure you that it is working more and more every day. Believe me, the physicians that refer us the work know the difference between facilities that are a good value and facilities that offer ‘low-ball’ rates. They want a good value (excellent service and products at a fare price). If we all take this stance, they will have no choice but deal with us as respectfully as we carry ourselves in our profession. Although we are all each others competition in one way, we don’t have to be unhealthy competitors. We must be healthy competitors, competing in quality and service, not in price. Mike, I want to urge you to fight the good fight and keep the faith. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
you are only off your rocker if the add ons are artifically inflating your reembursement. It has been the problem for some years that this has been the case. Our profession needs to be very careful not to be too greedy or creative or there will be more repercussions then already exist. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, I agree with your “logic” in this coding situation. The orthosis with a polycentric joint costs you more than if you bought the same orthosis with a single axis joint. That is what the coding system accounts for. Good luck. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike:You may want to approach the insurance company from a cost analysis perspective. You know your business and what it takes to keep it solvent. For instance, if you spend 30% of company income on payroll and employee expenses, 30% on general overhead (electricity, mortgage or lease, equipment, etc.), 30% on actual component costs, and maintain a 10% profit…then you can “back into” justification of charges using your formula. Accordingly, if the total cost of components in question is $500, an equal amount should be added for payroll and overhead to provide the service along with the 10% for your profit. This brings the justifiable charge for the service to about $1670…$500 for components (30%), $500 for overhead (30%), $500 for employee expenses (30%), and $167 for profit (10%). Of course, you use whatever formula fits your business. This is just one example of the cost analysis concept. You may have an easier time justifying your charges if you have a concrete formula for determining expenses, rather than trying to justify based on the arbitrary consideration of charges you assume to be rolled in by the manufacturer. Of course it depends on the people you are negotiating with.Good luck.
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