Denials are difficult to identify and time consuming to appeal. When you have a question, turn to ‘Got FAQs?’ to help get your billing back on track. This month’s column takes on your questions regarding billing for therapeutic shoes and inserts, crossover claims, knee-orthosis addition codes, and more.
Q: I have a prescription from a podiatrist requesting soft-soled shoes. The only shoes that we provide are Dr. Comfort diabetic shoes. This patient is not diabetic—she has keratodermia and a right foot amputation. The patient’s insurance is Medicare and Medicaid. After reading both Medicare and Medicaid’s billing criteria, I am more confused than ever about whether or not they will pay for her shoes and inserts. What guidance can you provide?
A: The answer depends on whether the shoes will be attached to a brace. Medicare covers therapeutic shoes and inserts for persons with diabetes. The need for therapeutic shoes must be certified by a physician who is an MD or DO and who has the primary responsibility for treating the patient’s systemic diabetes. Medicare will cover therapeutic/orthopedic shoes if the patient is either a diabetic or the shoe is going to be attached to a brace. To read the complete coverage criteria for diabetic shoes, visit www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11525&lcd_version=23&show=all
Q: My question is in regard to New Jersey Medicaid crossover claims. I have read your advice on the straight Medicaid submission of diabetic shoes and inserts, but I have crossovers for which I just cannot seem to get paid. Do you have any suggestions for what I can do or which codes I need to use, especially considering whether they have to match the Medicare EOB? Any suggestions would help
A: When billing New Jersey Medicaid for A-5500, use L-3224 (women’s) or L-3225 (men’s). For A-5501, use L-3216. For A-5512, use L-3002. For A-5513, use either L-3020 or L-3030. The A-Codes you billed Medicare for are not recognized in New Jersey Medicaid’s fee schedule. You must change the A-Codes to L-Codes with no modifiers in order to be paid for the co-insurance from Medicare. You may want to verify why your crossover claims are not being paid since you were not specific as to your denial reasons.
Q: After I read your answer about elastic garments, I wanted to make changes in our software. I needed to indicate that Medicare was not covering elastic garments after April 1, 2009, but wanted to be sure this was correct before doing it. I visited the website you recommended, www.dmepdac.com/dmecsapp/do/search. Using this site, I cannot verify that elastic garments are no longer covered. I have tried clicking on the code to go deeper, and I can see the history of the code, but there is no coverage end date showing. Are they just behind in this documentation, or am I missing something?
A: Try this link: www.medicarenhic.com/dme/medical_review/mr_lcd_current.shtml. Hopefully, it will be easier for you to use and will provide the information you are looking for.
Q: Can you tell me what addition codes I can bill separately to Medicare when using L-1840 as my base code?
A: When billing Medicare for L-1840 (knee orthosis, medial-lateral, anterior cruciate ligament, custom fabricated), these are the addition codes eligible for separate payment: L-2385, L-2390, L-2395, L-2397, L-2405, L-2415, L-2425, L-2430, L-2492, L-2785, L-2795. Addition codes may be eligible for payment if they are provided with the related base-code orthosis, the base orthosis is medically necessary, and the addition is medically necessary.
Lisa Lake-Salmon is the executive vice president of Acc-Q-Data, which provides billing, collections, and practice-management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact or visit www.acc-q-data.com
