Billing for O&P devices and care is complicated. When you have questions, count on Got FAQs? to help keep your claims on track. This month’s column answers your questions about coding verification and the reasonable useful lifetime of knee orthoses.
Q: As a relatively new facility owner, I consistently receive calls and visits from sales representatives with numerous manufacturers. They tell me their products are reimbursable by Medicare without issues. I recall reading somewhere that Medicare has a list of manufacturers and the codes assigned to their products. Is this mandatory for all products or just certain devices? I provide AFOs, knee braces, and therapeutic shoes for patients with diabetes. I am sure I will have many more questions for you in the future; you are a wealth of knowledge.
A: There have been several articles written about items requiring coding verification reviews by the Pricing, Data Analysis and Coding (PDAC) contractor. You can refer to the local coverage determinations (LCDs) and related policy articles that include these codes. Claims for these Healthcare Common Procedure Coding System (HCPCS) codes will be denied if the products requiring coding verification review are not listed on the PDAC Product Classification List. Within the product categories you referenced above, there is PDAC verification review coding for the specific L-Codes that follow:
L-1906: Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf
L-1845: Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
A-5512: For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each
A-5513: For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
To access the Product Classification List, visit the Durable Medical Equipment Coding System (DMECS) page, which is located on the PDAC website (www.dmepdac.com/dmecs/index.html).
Q: I recently had two patients come in who had unfortunate incidents, and the knee braces that my facility, located in Alabama, previously provided them need to be replaced. Both patients are Medicare beneficiaries, and I am not sure if these would be covered again. What does Medicare consider a reasonable useful lifetime (RUL) for a brace? One patient received an L-1836 (knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf), and the other received an L-1845 (knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/ valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise).
A: According to Medicare policy, if a same or similar item is provided during the RUL of an item already in the beneficiary’s possession, Medicare will deny it as same/similar. The RUL for L-1836 and L-1845 is three years. Replacement during the RUL is covered if the item is lost or irreparably damaged. For a replacement to be covered, a new physician order is needed to reaffirm the medical necessity of the item. The applicable replacement modifier to use is RA - Replacement Orthotic Item. Any additional codes will only be paid if the base code is covered.
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.
