L-codes/laws/&abilities

L-codes/laws/&abilities

Forest R Sexton CPO

There seems to be a great deal of debate over who can and should provide O&P
services under the new federal regulations. I'd like to break it into two
distinct questions and share my views with the list.

#1 Who is qualified to provide the products and services associated with
L-code billing.

#2 Who should the tax payers and private insurance be willing to pay for the
products and services associated with L-code billing.

  Let me first express my understanding of the role of credentialing bodies.
To the best of my knowledge all forms of credentialing have the same goal.
This goal is consistent whether it be licensing, certification, or
apprenticeships. It is to ensure the public/consumer that they will receive
an agreed upon minimum, standard of product, quality, care, or service.

 ABC credentials only indicate that a person has achieved entry level
competency to perform certain skills. As in all vocations some ABC
practitioners are more skilled in certain areas than others. It is a noted
fact that ABC requires greater preparation to set for it's exams than any
other O&P specific body. I think it is also fair to argue that ABC
credentialing standards monitor and test for a larger set of skills and
abilities than it's competing credentialing bodies. I would therefore argue
that ABC has a better opportunity to consistently accomplish it's mission
than does any other competing credentialing body. ABC therefore deserves it's
reputation as the credential of choice as well as the corresponding pay and
status it's completion offers.

 When I say, competing credentialing bodies, I do not limit myself to just
BOC. It is apparent that cast technicians, PT's, OT's, MD's, C-Ped's,
Podiatry, Chiropractic, Pharmacy, and perhaps other groups as well, wish to
hold up their credentials to be satisfactory to ensure minimum levels of
quality of care in the O&P industry. Perhaps in some cases they are.

  I find it difficult to argue that many military trained orthotists are not
qualified to provide Orthotics services in the private sector because they
lack a degree. I've been through both and believe that many aspects of my Air
Force training were superior to it's corresponding civilian counterpart. This
may very well be true for other forms of learning in our industry for which I
am unfamiliar, including apprenticeship. The difficulty is in consistently
proving it. If we want to hold ourselves up as a profession unfortunately the
threshold by law is a bachelors degree and all that it provides to round out
an individual.

  I also find it difficult to argue that I am better qualified than other
professionals when looked at narrowly. A PT who specializes in knee injuries
and has made great effort to research the biomechanics of all available knee
braces, may certainly be deemed more qualified to select the appropriate
brace than a CO who sees one ACL tear a year. This concept can easily be
argued about low temp hand orthosis' and OT's, foot Orthotics and
podiatrists, etc., etc.

  Although I argue that ABC is the most effective, comprehensive, and
consistent way to ensure quality O&P service, I openly admit that it is not
the only way.

  Now more importantly we must consider who can use L-codes. This is a huge
loop hole in the recently approved federal legislation. I believe too much
time has been spent arguing who is qualified to use them, and not enough time
has been spent analyzing who should use them.

  To the best of my knowledge L-codes were arrived at in an attempt for
M-care to establish universal billing guidelines in O&P. They were intended
to include product as well as time, care, and follow-up service. This is
critical in the custom arena, since it is impossible to standardize follow-up
from one patient to the next, and cost containment would be impossible if
office visits were billed independently. The concept of warranty also goes
out the window if O&P modification and adjustment could be invoiced by office
visits regardless of the age of the product. I believe though, that this
happens every day in therapy and medical offices around the country who are
using L-codes to bill for products. If I use my PT time to have my brace
adjusted, my insurance was just billed for the follow up that it already paid
for.

  M-care and many M-caid guidelines mandate that a service be provided in
order to use L-codes. There are in fact different coding schemes devised to
cover the cost of the product that exclude the professional fitting and
service time.

   I have been led to believe that physicians are only allowed to write up
the hard cost of DME 30% when they distribute it directly. I know that this
rule is to prevent physicians from enriching themselves by their own
referrals, but I believe it is also to prevent their access to L-codes and
the double billing that it represents. In fact there are businesses that
exist solely to circumvent this regulation.

   This is where the recently devised law is fouled. As far as I know OT's
PT's and most physicians are compensated for their time spent with patients.
This is done in the form of office visits or care units. If they also bill
under an L-code scheme which includes the time spent fitting and maintaining
the orthosis they are in effect double billing M-care. This is considered
Medicare fraud. I wonder how many PT's know this. I am also left to wonder if
the current bill can be disputed in court on these grounds.

  We need to protect L-codes for the express use of people who do not
separately bill for their time, and have the skills to follow up and maintain
the product. Or we need to even the playing field and be allowed to
separately bill for our time and follow up as our competitors do.

  I would like to close by applauding AOPA for the success they have achieved
thus far. Keep up the good fight.

Forest R Sexton CPO