Time to Modify

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Erin Cammarata

When I say, “You’re getting behind; you need to modify,” most practitioners will think about all those patients that they’ve taken cast impressions for but haven’t modified their molds yet. Lab work, right?

This month’s topic may make your lab work seem exciting. Because when I say, “You need to modify,” I’m referring to your present strategies for staying current with Medicare notifications.

In the past five months, I have received countless Medicare policy notifications. There are policy additions, policy modifications, reminders, notices, and clarifications. To deal with this staggering increase in notifications that are constantly piling up in our inboxes, we need to modify the way we deal with them.

Here is a summary of a few recent notifications I have received, what they mean to your practice, and strategies to help you deal with them:

  • Coding - Definitions Used for Off-the-Shelf [OTS] versus Custom Fitted Prefabricated Orthotics (Braces) - Revised Joint DME MAC [Durable Medical Equipment Medicare Administrative Contractor] Publication: accessible at www.oandp.com/link/316. Medicare recently outlined how to determine what is considered a custom-fitted versus an OTS orthosis—specifically, which L-Code to use and what documentation is required.
        You need to be certain that your documentation justifies that the brace you custom fitted required substantial modification. Otherwise, it’s considered OTS and you must use the corresponding OTS L-Code. Medicare defines OTS as a prefabricated item that requires minimal self-adjustment such as being trimmed, bent, molded, assembled, or otherwise adjusted to fit the beneficiary. Minimal self-adjustment does not require the expertise of a certified orthotist or an individual with equivalent expertise. Medicare defines custom fitted as a prefabricated item that requires substantial modification, e.g., has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by a certified orthotist or an individual with equivalent expertise.
        I recommend printing the regulation and laminating it so your billing and clinical team can use it as a quick reference. I would also include something in your internal audit process to be sure your staff remains compliant with the new revision.
  • LCD [Local Coverage Determination] and Policy Article Revisions Summary for April 30, 2015: accessible at www.oandp.com/link/317. Medicare stated that L-0455 (Tlso flex trnk sj-t9 pre ots) now requires a CG modifier (policy criteria applied).
        If you are using the L-0455 procedure code, you must be sure that item meets all Medicare and Pricing, Data Analysis, and Coding (PDAC) requirements, and that your documentation meets the LCD requirements. If your claim meets the requirements at that point, you need to add the CG modifier to get the claim paid. This change may require you to modify your billing and scrub process.
  • Proof of Delivery [POD] Reminder - Joint DME MAC Publication: accessible at www.oandp.com/link/318. Medicare outlined that, in addition to confirming receipt of an item, the POD may also be used to determine correct coding and billing information for claims submission. Further, Medicare stated that reiterating Healthcare Common Procedure Coding System (HCPCS) code narrative is not adequate for POD purposes.
        Be sure to review your delivery slips and delivery process to ensure they meet Medicare’s reminder. Medicare is asking for the brand name and model number, serial number and manufacturer’s name, or part number. This will help Medicare identify the product. Medicare specifies that if this information is not available, the supplier may use a detailed narrative of the item that must contain specific descriptive information.

So what should you modify? Well, if any of the above notifications are news to you, my first recommendation is to modify your process for retrieving and keeping up to date with Medicare regulations. It is critical to your practice’s success to be aware of all these updates. You need to know the new Medicare policies, procedures, and requirements, and how and when Medicare wants you to comply with those policies, procedures, and requirements. It is imperative to be informed of these changes as soon as possible so you can educate your staff and reiterate the information to others in your practice.

Step 1: Visit your DME MAC’s website and sign up for its listserv. It’s easy. It’s free.

Step 2: Participate in Medicare educational seminars. Seminar listings can also be found on your DME MAC’s website.

If we modify our present strategies, we can stay ahead and handle anything Medicare throws our way.

Erin Cammarata is president and owner of CBS Medical Billing and Consulting, Hampton Falls, New Hampshire. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact .

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