Ten Things You May Not Know About Reimbursement
By Joe McTernan, AOPA Government Affairs Department

For the last few years, one of the most popular sessions at the AOPA National Assembly has been the Top Ten Series. This is a series of short presentations on subjects the presenters feel will be most useful to the audience. The audience has grown every year, and now it’s often standing room only.

The increasing popularity of the Top Ten Series led to the question: How can AOPA pique the interest of its members regarding reimbursement issues throughout the year, instead of just at the annual National Assembly? And how can we get these vital bits of information to all members, not just those who fit in one conference room?

I can’t think of a better place than “Reimbursement Page” to present the first print version of the AOPA Top Ten Series. This month’s column will focus on 10 things that you may not know about O&P Medicare reimbursement.

1. Shoe inserts are sometimes covered by Medicare.
AOPA staff members receive several phone calls each month from confused O&P professionals who want to know why the Medicare fee schedule contains reimbursement values for shoe inserts. If Medicare does not consider them a benefit, why is there a fee schedule for these codes?

There are circumstances, however limited, where Medicare will cover shoe inserts as a benefit. Medicare covers shoe inserts for patients with diabetes. These are described by A codes and have their own unique set of coverage criteria. Shoe inserts described by codes in the L3000 series are also eligible for Medicare coverage when they are worn in a shoe that is an integral part of an ankle foot orthosis (AFO) or knee ankle foot orthosis (KAFO).

In order to be considered for coverage, the shoe must be necessary for the brace to function. If this is the case, Medicare will not only cover the shoe, it will also cover any inserts that are medically necessary for the patient. Shoe inserts that are not an integral part of a brace remain non-covered by Medicare.

2. Socket replacements are covered for preparatory prostheses.
Medicare lower-limb prosthetic policy does not place restrictions on the provision of replacement sockets during the preparatory phase of prosthetic management. If a Medicare patient has had a significant change in his or her condition and requires a new socket, but is not ready for a definitive limb, Medicare will often cover the socket replacement.

It is very important to document the specific medical need for the socket change. As with any component replacement, a new prescription is required in order for Medicare to cover the replacement socket.

3. You can bill Medicare for custom items that cannot be delivered.
Medicare regulations allow for reimbursement of custom made orthoses and/or prostheses that cannot be delivered when one of the following situations exists:

•    Patient death. If a patient dies before you can deliver a completed device, you may bill Medicare for the device, minus any salvage value of reusable components. The date of service on your claim should reflect the date of death.
•    Patient cancels the order. If the patient cancels the order for a custom device, you may bill Medicare for the portion of the device that was completed up to the date you learned of the cancellation. This date becomes the date of service on your claim.
•    There is a change in patient condition. If there is a change in condition that makes the custom device no longer medically necessary for the patient, you may bill Medicare for the portion of the device that was completed up to the point that you learned of the change in condition. Your date of service should match the date that you learned of the condition change.

4. Bilateral amputees are not strictly bound by functional level restrictions.
Medicare’s lower-limb prosthetic policy states that the DME MACs recognize that bilateral amputees cannot always be bound by strict functional level guidelines. While this does not allow you to provide components that are beyond your patient’s medical need, it does provide some leeway if a specific component may provide additional stability for your patient. The specific advantage that the higher functional level component offers your patient must be documented in the patient’s chart.

5. Claims with minor errors do not have to go through the formal appeals process.
Each of the DME MACs, which process claims on behalf of the Medicare program, has a mechanism in place to allow a claim with minor errors or omissions to be corrected. This process, called reopening, saves providers time by not forcing them to enter into the formal appeals process. It also saves the DME MAC time and money because it does not have to move the claim into the appeals process and have dedicated review staff look at the claim again.

If a claim is denied due to a clerical error such as an incorrect procedure code, missing modifier or incorrect date of service, you may contact your DME MAC and ask them to reopen the claim. Contact information for the reopening line for your specific DME MAC may be found in your supplier manual or on your DME MAC’s Web site.

6. Repairs, replacements and adjustments in the first 90 days may be billable to Medicare.
Medicare policy states that adjustments and repairs within the first 90 days of delivery are included in the reimbursement for the original device. While this is true for patients who have had no change in their condition, Medicare will cover repairs that are warranted by a change in the patient’s condition that makes the device no longer usable. If this occurs, you may bill Medicare for repairs, replacements and adjustments that are necessary to make the device function properly.

7.  Medicare covers AFOs for treatment of plantar fasciitis.
Medicare AFO/KAFO policy allows the use of non-ambulatory AFOs to treat plantar fasciitis. These devices should be coded as L4396, which is the same code used to describe ankle contracture orthoses. Policy requires multiple conditions to be met when managing ankle contracture with an orthosis, but only requires a diagnosis of plantar fasciitis in order to cover a static AFO.

8. Medicare will pay for unlisted codes.
Some believe that Medicare does not pay for unlisted codes. This is simply not true. While it may not be easy to get miscellaneous codes reimbursed, if you give the DME MAC sufficient information, they may pay your claim. The key is information. If you want to be reimbursed a specific amount, you must be prepared to submit the relevant details to justify your claim.

9. Medicare rules place no “useful lifetime” restrictions on prostheses.
While Medicare policy states that the useful lifetime of an orthosis is five years, prostheses may be replaced any time it is medically necessary, regardless of how old they are. Replacement of any component requires a new physician’s order, and Medicare regulations state that if it has been less than three years since provision of the original device, the provider may have to submit additional documentation to support the medical need for the replacement.

10. Ask the right questions when talking to SNFs and hospitals.
When you receive a referral to see a patient in a hospital or SNF, you need to make sure you are aware of the patient’s Medicare status. Since many services are “bundled” into the Part A payment to the hospital or SNF, you need to ask the right questions so you know whether to pursue a purchase order from the SNF or hospital or to submit your claim to the DME MAC.

While the referral may come to you from clinical staff such as physicians, nurses or therapists, you should talk to the staff in the business office of the facility about billing arrangements. They will most likely know the specific Medicare status of the referred patient and provide you with the information you need in order to file your claim.

The 10 things highlighted above by no means encompass all of the reimbursement challenges that O&P professionals face today. However, based on the popularity of the AOPA Top Ten series during the National Assembly, the need for this information appears to remain very high. Hopefully, this month’s article leaves you a little more savvy about the intricacies of reimbursement.

Joe McTernan is director of reimbursement services for AOPA. Questions? Call (571) 431-0876, ext. 211, or email jmcternan@AOPAnet.org.