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Denials are difficult to identify and time-consuming to appeal. Count on Got FAQs? to help ensure you are using the most current information when preparing your claims. This month's column answers your questions about documentation requirements when billing for therapeutic shoes and inserts, and correct codes to use when billing for a transtibial Infinite Socket™.
Q: I recently opened my own office and initially will be doing the billing myself. I have a few questions regarding billing for diabetic shoes and inserts, and have received conflicting information. Who can sign the order for the shoes? If the patient needs additional inserts, will I need a new prescription on file each time? I appreciate your contribution to the O&P community over the years. I know you will be able to assist me.
A: A new prescription and detailed written order is required to replace shoes, replace inserts, or make modifications more than one year from the most recent order on file. If you provide additional inserts or make modifications within one year of the order on file, a new order is unnecessary. I suggest that you document the reason for the replacement in your records.
The order must be signed on or after the date of the patient's visit with the prescribing practitioner. The supplier must obtain a signed statement from the practitioner who is managing the beneficiary's systemic diabetes condition. The signed statement must specify that the beneficiary has diabetes mellitus, has one of conditions listed in the related Policy Article, is being treated under a comprehensive care plan for his or her diabetes, and needs therapeutic shoes. The certifying physician must be a medical doctor (MD) or doctor of osteopathic medicine (DO), and may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.
I recommend using the Statement of Certifying Physician for Therapeutic Shoes form, which can be found at www.oandp.com/link/353. This statement must be completed, signed, and dated by the certifying physician. A new certification statement is required for a shoe, insert, or modification provided more than one year from the most recent certification statement on file. To access the Local Coverage Determination (LCD): Therapeutic Shoes for Persons with Diabetes (L33369), which includes a link to the Policy Article, visit www.oandp.com/link/354.
Q: I recently fitted a patient with a transtibial Infinite Socket by LIM Innovations, San Francisco. Do you have any information about the code or codes I should use to bill for this when I am replacing a patient's old socket? My facility is in the southeast. Any information you provide will be appreciated.
A: On December 8, 2016, Medicare issued an update titled LIM Innovation Below Knee Socket - Correct Coding. It stated: Infinite Socket (LIM Innovations) is an open-frame below-knee socket design. This product uses struts that extend from a base to an adjustable brim enclosing an inner shell to form the structure of the socket. It is custom-fabricated from a model of the patient's residual limb. Although the LIM Innovations Infinite Socket is different in design from traditional sockets described by the existing L-codes, it has been determined that the socket design has critical design elements to meet the coding requirements for the following HCPCS [Healthcare Common Procedure Coding System] codes. The correct combination of HCPCS codes to bill Medicare for this item follow: Base code for socket replacement: L-5700 (replacement, socket, below knee, molded to patient model).
Addition codes to always bill with L-5700: L-5629 (addition to lower extremity, below knee, acrylic socket); L-5637 (addition to lower extremity, below knee, total contact); and L-5940 (addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal). The add-on codes L-5629, L-5637, L-5940, and the HCPCS codes describing the choice of suspension must be included on the same claim for the socket replacement. To read the coding publication, visit www.oandp.com/link/355.
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 over 20 years. 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.
