Tuesday, May 28, 2024

Humana Adv and DM shoes/inserts w/brace txfr

Tracy Fields

Hello Listserv, hope this email finds you well.

I am looking for advice.

I have run into an issue with Humana Advantage recently and I am not sure
about the correct way to proceed. This has not been an issue before until
post pay review.

We billed for DM shoes/inserts w/brace txfr

A5500 x2 RTLTKX
A5514 x6 RTLTKX
L3620 x1 LTKX

I coded all A codes with a diabet dx code pointer and the brace txfr was
coded with the appropriate dx as to why the pt wears the brace which was
not a diabetic dx code. This claim paid fine with no issues.

Received post pay review and submitted records which show all appropriate
dx issues that are valid.

Humana pulled back my payment on the brace txfr stating it was not to be
billed with a diabetic dx. No problem, I submitted an appeal showing how I
never billed the claim pointing that code to a diabetic code as well as the
records justifying the dx I did bill it with (the records were the same
records for the DM shoes/inserts though). My appeal came back denied, still
quoting it is not to be billed with DM codes. I even asked if this person
was not allowed to have multiple health problems or if we were not allowed
to bill the service together.

Due to this problem on a new pt I decided ok I will bill this differently.
So I billed the following

One claim went out as.
A5500 x1 RTKX
A5514 x6 LTRTKX

Another claim
L3225 x1 LTKX (shoe w/attached brace because there is not a diabetic A code
for that)
L3620 x1 LTKX

They paid the non diabetic claim and they paid the DM shoes on the other,
but denied all of my inserts indicating they are not billable with
orthopedic shoes. I did a corrected claim to split the A5514 to show the
modifier in a different layout to get the corresponding ones to the A5500

What am I doing wrong here? Obviously if a pt wears a brace they will need
it transferred. He wears shoes/inserts for diabetes but wears a double
upright for another reason. I have indicated that on claims and they paid
no problem before. Why has this become an issue?

Thank you

*Tracy Fields*
Billing Specialist

*First Step Prosthetics*

*Kentucky Location:*

1136 US 31W Bypass, Bowling Green, KY 42101
Phone 270.904.6130 / Fax 270.721.0749

*Tennessee Location:*

728 Nashville Pike, Gallatin, TN 37066
Phone 615.461.8557 / Fax 615.461.8581


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