Billing and Collections Q&A

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Billing for O&P devices and care is complicated. Count on “Got FAQs?” to help ensure you are using the most current and accurate information when preparing your claims. This month’s column addresses your questions about using DX code 727.66 when billing for L-1843, L-1844, and L-1846 and whether it is necessary to acquire an Advance Beneficiary Notice when billing Medicare for statutorily noncovered items.

Q: I am having a dispute with the practitioner for whom I work about whether a specific diagnosis (DX) code is acceptable when billing Medicare for L-1843, L-1844, and L-1846. I have billed in the past for these L-Codes, and if my patient’s diagnosis was 727.66 (rupture of tendon, nontraumatic, site-patellar tendon) my claim was denied for not being medically necessary. My boss said he read this is no longer the case. He does not know where he saw this, and it is up to me to find out if this is correct or not.

A: On August 22, the Centers for Medicare & Medicaid Services (CMS) issued an update to the local coverage determination (LCD) for knee orthoses. The knee orthoses LCD has been revised with the addition of diagnosis 727.66, effective for dates of service on or after August 15, 2013. International Classification of Diseases (ICD)-9 code 727.66 is covered for Healthcare Common Procedure Coding System (HCPCS) codes L-1830 (KO immobilizer canvas longit); L-1832 (KO adj jnt pos rigid support); L-1834 (KO w/o joint rigid molded to); L-1843 (KO single upright custom fit); L-1844 (KO w/adj jt rot cntrl molded); L-1845 (KO w/ adj flex/ext rotat cus); and L-1846 (KO w adj flex/ext rotat mold). For complete information concerning coverage criteria, coding guidelines, and documentation requirements, visit www.oandp.com/link/238. To read the August 22 update, visit www.oandp.com/link/239

Q: We are starting to bill Medicare for items that we know are noncovered. We need to bill Medicare to receive a denial so we can then bill the secondary insurance. Do I need to have the patient fill out an Advance Beneficiary Notice (ABN) form if the item we are providing is considered “statutorily noncovered,” as stated by the practitioner for whom I work? I do not know what he meant by “statutorily noncovered.” I tried calling Medicare and was unable to get an accurate answer on whether or not I need to have the patient complete an ABN and if I use the GA modifier (waiver of liability statement on file) or another one.

A: ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e., care that is never covered) or fails to meet a technical benefit requirement (i.e., lacks required certification). However, the ABN form CMS-R-131 (03/11) can be issued voluntarily. The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Some LCDs require the use of the GY modifier when the item or service may be excluded from coverage. In this situation, suppliers are instructed to code the claim with the appropriate HCPCS code indicated in the LCD and append the GY modifier. Modifiers GA and GY should never be coded together on the same line for the same HCPCS code. It is important to distinguish situations in which an item is denied because it is statutorily excluded or does not meet the definition of any Medicare benefit from those situations in which an item is denied because it is not reasonable and necessary. Examples of statutorily excluded items are orthopedic shoes or shoe inserts—other than those covered under the Therapeutic Shoes for Persons with Diabetes benefit or those that are attached to a covered leg brace. A description of the statutory benefit items that are processed by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) can be found in the DME MAC Jurisdiction C Supplier Manual, chapter nine. When billing for statutorily noncovered items under Social Security Act §1862(a)(1)(A), the GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily noncovered or is not a Medicare benefit.

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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