Billing for O&P devices seems to get more complicated by the day. Count on “Got FAQs?” to help answer your toughest questions. This month’s column addresses your questions about denial code CO222 and billing for lumbarsacral orthoses.
Q: The providers I work for are located in Texas, and I am new to billing for orthoses. We recently received more than 200 denials from BlueCross BlueShield (BCBS) of Texas for devices we provided. The L-Codes BCBS denied are not confined to a specific category. For example, a few of the codes that have been denied are L-0637 (lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lat); L-3908 (wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, off-the-shelf); L-0180 (cervical, multiple post collar, occipital/ mandibular supports, adjustable); L-0627 (lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L1 to below L5 vertebra, produces intracavitary pressure to reduce load on the intervertebral disc); and L-3670 (shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf). They were all given denial code CO222, stating that the charges were reduced because the service/care was partially furnished by another physician. Have you heard of this happening to any other provider? Also, how can I check the status of open claims with BCBS of Texas, and what is the filing time limit for claims?
A: According to provider relations at BCBS of Texas, if you received a denial with the reason code CO222 and the reason states the charges were reduced because the service/care was partially furnished by another physician, it was denied in error and will be reprocessed over the phone for payment if you contact customer service. These erroneous denials started in January 2014. I recommend that providers check to see if they have received similar denials and contact BCBS to get these denials reversed. I have seen this denial with numerous billing clients of Acc-Q-Data and have had thousands of claims reprocessed and paid since March.
The time limit for filing HMO Blue Texas claims is 180 days from the date of service. PPO, POS, and ParPlan claims must be filed within 365 days of the date of service. You can check claim status and verify claim denial descriptions by phone or online. When checking claim status, you can verify if your claim has been received, is pending, or was finalized. Call the BCBS of Texas automated phone system at 800.451.0287. Online access is available through the Availity® Claim Research Tool, which provides the equivalent of an Explanation of Benefits (EOB), including detailed denial descriptions. To access the Availity tip sheet, visit www.bcbstx.com/provider/pdf/availity_crt_online_tip_sheet.pdf. To access the Availity system, visit www.availity.com
Q: I work for practitioners who are located in Florida. Are there any new codes for lumbar-sacral orthoses (LSOs) for 2014 that include prefabricated, off-the-shelf (OTS) in their descriptions? Also, which codes for these devices are considered custom fitted, and which codes are considered custom fabricated?
A: Effective January 1, the new 2014 codes for LSOs are as follows: L-0641, L-0642, L-0643, L-0648, L-0649, L-0650, and L-0651. LSOs that require substantial modification by a qualified practitioner, coded as custom fitted, are L-0626, L-0627, L-0630, L-0631, L-0633, L-0635, L-0637, and L-0639. LSOs that are considered custom fabricated are L-0629, L-0632, L-0634, L-0636, L-0638, and L-0640. There must be detailed documentation in the treating physician’s records to support the medical necessity of a custom-fabricated LSO rather than a prefabricated LSO as described in the Local Coverage Determination. This information must be corroborated by the functional evaluation in the orthotist’s or prosthetist’s records.
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
