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 the 2017 Medicare deductible, replacement codes for knee orthoses K-0901 and K-0902, and correct coding to use for the Ottobock C-Leg.
Q: My husband is a practitioner and has been an avid reader of your column for the last ten years. You are informative and explain things in a way that always makes sense to the staff. Can you provide us with the 2017 yearly deductible as I was told it has changed? Also, we received denials on claims for K-0901 stating the code is no longer valid. When did this change and what code should we now use?
A: The 2017 deductible rate is $183. To view the Centers for Medicare & Medicaid Services article, “Update to Medicare Deductible, Coinsurance and Premium Rates for 2017,” visit www.oandp.com/link/345. You received a denial for K-0901 because that code and K-0902 were discontinued for 2017 and replaced by L-1851 and L-1852, respectively, as follows:
K-0901 was replaced by L-1851: Knee orthosis (KO), single 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, off-the-shelf.
K-0902 was replaced by L-1852: Knee orthosis (KO), 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, off-the-shelf.
To access the 2017 HCPCS [Healthcare Common Procedure Coding System] Code Annual Update, visit www.oandp.com/link/346.
Q: I recently started working for an O&P office in Alabama. We have a patient who has been evaluated by his physician and prosthetist and both agree the patient would be best suited with an Ottobock C-Leg. The beneficiary is a level-3 ambulator. I have never billed Medicare for this type of prosthesis, and the practice owner requested I check with you as this is an expensive device and we want to make sure we are billing the correct codes.
A: According to Medicare claim review, there appears to be a misunderstanding among suppliers about the correct coding of the various electronic and microprocessor-controlled knee (MPK) systems. Because not all MPK systems are identical in features and functions, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are unable to designate a single set of HCPCS codes to be used for all products. The DME MACs issued a joint publication, most recently revised October 6, 2016, (originally published July 14, 2008, and revised January 31, 2013) titled Otto Bock C-Leg Correct Coding, which states the following:
The Otto Bock C-Leg is a microprocessor- controlled prosthetic knee. The product is covered by Medicare for beneficiaries classified as K-level 3 or 4. This HCPCS coding determination has been reevaluated at the company’s request. Effective for claims with dates of service on or after the publication date of this article, only the following codes may be used to bill Medicare for this product:
- L-5828: addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control n L-5845: addition, endoskeletal, knee-shin system, stance flexion feature, adjustable
- L-5848: addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability
- L-5856: addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
This coding information can be found at www.oandp.com/link/347.
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.
