Responses-Medicare shoe billing
Randall McFarland, CPO
Description
Collection
Title:
Responses-Medicare shoe billing
Creator:
Randall McFarland, CPO
Text:
Original post:
1) We've been told by Medicare that L3222 (high top shoes) is not recognized
anymore.
How do I bill for high top shoes now?
2) A while back, I submitted an extra 2.5 hour labor (L4305) billing for
significant extra modifications to a shoe/stirrup for a KAFO (welding a
medial extension on a long tongue stirrup and custom soleing for
weightbearing to accommodate a deformed foot/ankle). I included a thorough
description, photographs and pictures of X-rays of what we did. It came
back denied, saying that the extra work should be included as part of the
other procedures.
Q) Is this happening to everyone? Is there a way to get paid for shoe work?
3) Is a CMN required to get paid for shoes attached to an orthosis?
4) Is it wise to accept assignment for shoes and modifications?
Randy McFarland, CPO
Responses, separated by a blank line
1. You are correct, L3222 is not covered with Medicare even when attached to
a brace. Interesting, as this code was intriduced for the Brace Boots we
all think of attaching to braces. It might be something to mention to HCFA,
if you want to request a policy change before April 1st. (PS Don't feel
alnoe, I got burned on it myself about 3 years ago)
2. Your special modifiations should be L3649 codes with complete
descriptions. Make sure you separate codes you used from the special extra
modifications you did. It should be covered. You need to supply meical
documentation - although is sounds as if you did. Good luck. ( They don't
pay for labor and materails as a rue with other based/addition codes)
3. A CMN is not necessary, jus tthe ususal paperwork in your files. And a ZX
modifier to the L3649 code, if it is attached to a shoe( as it was in this
case>)
4. You cannot seectively accept assignement on part of a claim, the whole
thing/ or part. If you believe the service will not be deemed medically
necessary, you can GA modify the scode and get a Waiver signed for those
speceific code you hve concern about.
At one of the more recent national meetings I remember someone saying, I'm
surprised any of you would accept Medicare assignment. In the 'olden'
days', we didn't. Oldsters would just bring in the Medicare check when it
came and pay the balance. Yep, the good old days. Now, I decided to accept
assignment because most everyone who walks in the door says, Do you accept
Medicare assignment? Since this town of 140,000 only has Hanger and us
(=ma+pa shop), I figured I'd be better off accepting.
I have been refused by Medicare in the last year alone, bilateral
prostheses on a blind, diabetic patient who just had a kidney transplant
(from his wife), an A/K replacement socket for a gal who never had a
prosthesis. After Dave made her one, and got her up and going, she started
feeling better about life and indulged in way too many root beer floats.
She'd gain, and then cut them out and lose, up and down, so Dave replaced the
socket with a flexible wall one. No dice.
Every time I read him the denials from insurance companies and their
lame excuses not to pay, he gets the look on his face like this just isn't
worth it anymore. He's made several prostheses and replacement sockets for
free because he knows darn well that if it doesn't meet the 'holy' criteria
of the payor that it won't be paid anyway.
I had a front office person working for us last year who, when she'd get
the letters from Medicare that say, you must respond in 30 days, she'd just
file them in the amputees folder because she thought since she'd sent the
bill in that was sufficient. Now they're way to old to collect on.
1) We've been told by Medicare that L3222 (high top shoes) is not recognized
anymore.
How do I bill for high top shoes now?
2) A while back, I submitted an extra 2.5 hour labor (L4305) billing for
significant extra modifications to a shoe/stirrup for a KAFO (welding a
medial extension on a long tongue stirrup and custom soleing for
weightbearing to accommodate a deformed foot/ankle). I included a thorough
description, photographs and pictures of X-rays of what we did. It came
back denied, saying that the extra work should be included as part of the
other procedures.
Q) Is this happening to everyone? Is there a way to get paid for shoe work?
3) Is a CMN required to get paid for shoes attached to an orthosis?
4) Is it wise to accept assignment for shoes and modifications?
Randy McFarland, CPO
Responses, separated by a blank line
1. You are correct, L3222 is not covered with Medicare even when attached to
a brace. Interesting, as this code was intriduced for the Brace Boots we
all think of attaching to braces. It might be something to mention to HCFA,
if you want to request a policy change before April 1st. (PS Don't feel
alnoe, I got burned on it myself about 3 years ago)
2. Your special modifiations should be L3649 codes with complete
descriptions. Make sure you separate codes you used from the special extra
modifications you did. It should be covered. You need to supply meical
documentation - although is sounds as if you did. Good luck. ( They don't
pay for labor and materails as a rue with other based/addition codes)
3. A CMN is not necessary, jus tthe ususal paperwork in your files. And a ZX
modifier to the L3649 code, if it is attached to a shoe( as it was in this
case>)
4. You cannot seectively accept assignement on part of a claim, the whole
thing/ or part. If you believe the service will not be deemed medically
necessary, you can GA modify the scode and get a Waiver signed for those
speceific code you hve concern about.
At one of the more recent national meetings I remember someone saying, I'm
surprised any of you would accept Medicare assignment. In the 'olden'
days', we didn't. Oldsters would just bring in the Medicare check when it
came and pay the balance. Yep, the good old days. Now, I decided to accept
assignment because most everyone who walks in the door says, Do you accept
Medicare assignment? Since this town of 140,000 only has Hanger and us
(=ma+pa shop), I figured I'd be better off accepting.
I have been refused by Medicare in the last year alone, bilateral
prostheses on a blind, diabetic patient who just had a kidney transplant
(from his wife), an A/K replacement socket for a gal who never had a
prosthesis. After Dave made her one, and got her up and going, she started
feeling better about life and indulged in way too many root beer floats.
She'd gain, and then cut them out and lose, up and down, so Dave replaced the
socket with a flexible wall one. No dice.
Every time I read him the denials from insurance companies and their
lame excuses not to pay, he gets the look on his face like this just isn't
worth it anymore. He's made several prostheses and replacement sockets for
free because he knows darn well that if it doesn't meet the 'holy' criteria
of the payor that it won't be paid anyway.
I had a front office person working for us last year who, when she'd get
the letters from Medicare that say, you must respond in 30 days, she'd just
file them in the amputees folder because she thought since she'd sent the
bill in that was sufficient. Now they're way to old to collect on.
Citation
Randall McFarland, CPO, “Responses-Medicare shoe billing,” Digital Resource Foundation for Orthotics and Prosthetics, accessed December 27, 2024, https://library.drfop.org/items/show/215966.
