Got FAQs?

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Denials are difficult to identify and time consuming to appeal. Because we know you want to do it right the first time so your payments are not delayed, count on "Got FAQs?" to answer your most pressing Medicare and reimbursement questions.

Q: We have started a patient services division to fit our custom breast prosthesis. We know how to bill for the prosthesis but are unsure what else we should bill for and under what code. Can we bill for casting time, fitting time, and the associated supplies?

A: You did not specify if you were billing DMERC or a commercial carrier; therefore, I will give you Medicare's guidelines. Casting and fitting are included in the reimbursement for the prosthesis. In addition to the prosthesis (L-8030), you can either bill for a mastectomy bra (L-8000, L-8001, or L-8002) or adhesive skin support attachment (A-4280), but not both.

Q: We are restructuring our company and have changed from a limited liability corporation (LLC) to an S corporation (S-corp). We received a new tax ID and are not sure if we need to send a W-9 form to Medicare to advise of this change or if we can just call them directly.

A: DMEPOS suppliers must notify the National Supplier Clearinghouse (NSC) within 30 days of changes in their enrollment information. If your tax identification number is changing, you will have to fill out a new supplier enrollment form (CMS 855-S), which can be found online at www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf. You may contact the NSC directly at 866.238.9652.

Q: Can you advise us as to what is required for L-4210 (unlisted parts)? Can we bill with labor (L-4205)? Do they need modifiers or require an invoice?

A: L-4210 requires an RP modifier, then RT or LT. You will need a specific breakdown of parts and/or components being replaced or repaired. This documentation will go in your note segment field, also known as the HAO field. In addition to L-4210, you should bill L-4205 (labor for repair/replacement of parts) with the same modifiers as L-4210. When billing for L-4205, each unit represents 15-minute segments. You must give a breakdown of exactly what you repaired for the labor time being billed.

Q: If the physician who treats a patient's diabetes sends the patient to a podiatrist for issues relating to the feet, is it acceptable to use the podiatrist's notes or patient records to support medical necessity?

A: The documentation in the patient's record from the podiatrist would be considered acceptable. The particular type of footwear (shoes, inserts, modifications) must be prescribed by a podiatrist or other qualified physician, who is knowledgeable in the fitting of diabetic shoes and inserts. The footwear must be fitted and furnished by a podiatrist or other qualified individual such as a pedorthist, orthotist, or prosthetist. 

Lisa Lake-Salmon is the executive vice president of ACC-Q-Data, which provides billing, collections, and practice management software and 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. For more information, contact lisa@opedge.com

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