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Lisa Lake-Salmon

Running an O&P practice is complicated enough without having to sort through Medicare guidelines to determine the reason for a denial. “Got FAQs?” can help guide you through Medicare’s maze. This month’s column addresses your questions about Medicare deductibles, denials due to invalid place of service, AFO replacements, and billing repairs to Medicare.

Q: I am a billing manager for a West Virginia O&P provider. We are starting to see patients who have not met their 2010 Medicare deductible and were wondering if the yearly deductible is still $140? I also received a denial for L-3672 stating it is no longer a valid code. Do you know if there is a code that replaced it? Finally, are there any new L-Codes for AFOs?

A: The 2010 yearly Medicare deductible was $155. For 2011, the Medicare deductible has increased to $162. Effective January 1, 2011, L-3672 and L-3673 will be discontinued and replaced by L-3674. To date, the only AFO L-Code that was added is L-4631 (Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated).

Q: I recently opened my own O&P practice in Alabama. I am trying to do my own billing and have submitted numerous claims to Medicare. All were denied for the same reason: "treatment was rendered in an inappropriate or invalid place of service." We provided the patient with the brace in our office, so I used place of service (POS) 11 (office). I am totally confused by the denial, and when I spoke to a Medicare claims representative, I think she was even more confused than I was. Am I missing something?

A: When submitting a claim for a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) item, the POS is considered to be the place where the patient will primarily use the device. Therefore, in your situation, your POS would be 12 (home). You can resubmit your claims to Medicare with the correct POS 12, and they should be processed accordingly.

Q: Could you please tell me how often a patient who is covered under Medicare can get a new AFO—either L-1960 or L-1970? Is it every year?

A: According to Medicare's current guidelines, coverage depends upon the patient's medical necessity when a same or similar AFO is prescribed to a patient within five years of the initial brace receipt. Medicare will consider a replacement of a complete orthosis or orthotic component due to loss or significant change in the patient's condition. If the orthosis or orthotic component is accidentally, irreparably damaged, but is still medically necessary, Medicare will consider a replacement. The reason for the replacement must be documented in the supplier's record. You may view this information at www.cignagovernmentservices.com/jc/pubs/pdf/Chpt5.pdf

Q: We are having trouble billing repairs to Medicare, in particular when we replace Velcro straps (L-4002) on either a TLSO or an AFO. What are the correct modifiers? Do I need to describe the repairs?

A: When billing Medicare for L-4002 (Replacement strap, any orthosis, includes all components, any length, any type) on AFOs, you would use either the RT or LT modifier, in addition to the KX modifier. For TLSOs, you would use the KX modifier. I recommend that in your additional documentation record you give a clear description as to what type of device you are repairing and the type of strap you are replacing—for example Velcro straps.

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

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