Running an O&P practice is complicated enough, so if you receive denials on your claims and can't figure out why, turn to "Got FAQs?" to help get your billing back on the right track. This month's column addresses your questions about billing skilled nursing facilities, how long a practice must keep patient records, billing for custom breast prostheses, and more.
Q: I am an O&P provider in Florida. I have a handful of patients for whom I made prostheses who are in various skilled nursing facilities (SNF). One of those nursing facilities contacted me to furnish services, and they said that Medicare would reimburse me since the resident is not in a covered Part A stay. As it turns out, the patient was, in fact, in a covered Part A stay. Needless to say, Medicare denied my Part B claim. I am not getting anywhere with this SNF. Is there any information I can refer to that can help me get paid?
A: You should refer to section 10.4.2 - SNF and Supplier Responsibilities of the Medicare Claims Processing Manual at www.cms.gov/manuals/downloads/clm104c06.pdf. It states that "an SNF…must reimburse the supplier once such an error is called to its attention…. If...the SNF refuses to pay the supplier for the service even after being apprised of the inaccuracy of its initial information, the SNF would not be in compliance with consolidated billing requirements." When treating patients in a SNF, it is important to have supporting documentation in place for the service provided. This would also help to ensure compliance with the consolidated billing requirements.
Q: We are moving our offices, and I was informed that I need to keep all my patients' records for ten years. Is this true? Where can I find out how long I am required by law to keep all of my patients' records?
A: State laws usually determine how long medical records must be retained. However, the Health Insurance Portability and Accountability Act (HIPAA) administrative simplification rules requires a covered entity, such as a provider billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt state laws if they require shorter periods. You may go to www.cms.gov/MLNMattersArticles/downloads/SE1022.pdf for more information.
Q: I am new to a practice that provides breast prostheses. Can you tell me which diagnosis codes must be used with these L-Codes? Is there a list of all codes and definitions I can view? Any information on billing for breast prostheses would be greatly appreciated.
A: When billing for breast prostheses, the following diagnosis codes may be used: 174.0 through 174.9, 233.0, and V4571. The presence of an ICD-9 code by itself is not sufficient to assure coverage. You may go to the Local Coverage Determination (LCD) for more information at www.cms.gov/mcd/viewlcd.asp?lcd_id=11554&lcd_version=25&show=all
Q: I used to work for an O&P practice that used a specific form for physicians to sign when we provided a patient with diabetic shoes. I have since opened my own facility. Are you aware of such a form? If so, where I cay find it? I have looked everywhere on the Medicare Region C website and cannot find it.
A: I believe the form you are looking for is the Statement of Certifying Physician for Therapeutic Shoes. You may go to the following link to access the form: www.cms.gov/mcd/lcd_attachments/11525_16/certifyingphysiciantherapeuticshoesrevised2007.pdf
Lisa Lake-Salmon is the 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