Responses-Medicare- shoe billings reimbursement

Responses-Medicare- shoe billings reimbursement

Randall McFarland, CPO

Here are all the responses for your perusal. Thanks to those who took the
time to respond!!
   By the way, I compliment Kathy Dodson as well as the L coding committee
for their responsiveness to related matters that arise on this list. They
have almost always voluntarily contributed useful info. to the discussions.
Thanks also to everyone who contributed to the responses below.

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 (L4205) billing for
significant extra modifications to a shoe/stirrup for a KAFO (welding a
medial extension on a long tongue stirrup and custom soling for weight
bearing 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 introduced 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
alone, I got burned on it myself about 3 years ago)
2. Your special modifications 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 medical
documentation - although is sounds as if you did. Good luck. ( They don't
pay for labor and materials as a rue with other based/addition codes)
3. A CMN is not necessary, jus the usual 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 selectively accept assignment 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 code and get a Waiver signed for those
specific code you have concern about.
Remember, if you are a participating provider you have to accept
assignment. If you aren't, you may decide on a case by case basis.

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 almost 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 we 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 the practitioner
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.

As long as you accept assignment you cannot add extra labor. Accepting
assignment says you accept the max allowable for that procedure. I would not
accept assignment in that case and probably have the patient sign a waiver of
liability and assume the extra labor will not be understood or approved by
Medicare.

To answer your first question on hightop shoes the code change should have
been sent to you when you were denied under the L3222 code each DMERC was
supposed to update you on the proper code. In addition they may also use a
different code for shoes attached to a brace. If you call your DMERC they
should be able to send you their accepted codes. As to your labor question
the code for labor is different for some and sometimes it's being ignored by
the DMERC L4210 seems to work better as well as for Prosthetics L7510 even
though they are defined as replacement repair parts.
As far as accepting assignment we do not any longer accept assignment on
shoes unless they are diabetics with either secondary insurance or Medicaid
otherwise we have been charging the patient up front and submitting an
unassigned claim to Medicare.
Yes its happening to all of us, but if you are billing electronically you may
need to put an explanation in. As far as cmn or lmn they are usually ignored
unless you are appealing the claim

1. The only way is through non assignment as that is the rule. HOWEVER, my
advice, for now, is to go through the routine. The routine is: first ask
for a review and they are ALWAYS, summarily denied. Then ask for a Fair
Hearing. When asking for the Fair Hearing, make certain that you are
extremely well documented as to need. Remember, if this patient has always
worn high top boots, tell them. If you can get a specific letter of Medical
Necessity from the prescribing MD, that will surely help.
     2. See answer #1.
     3. NO, but don't forget to include the zx modifier.
     4. A root canal is a far more pleasant experience. Seriously, shoes and
shoe modifications are more of a pin than they'll ever be worth, but
sometimes you have to keep a doc happy.
     Remember, on denied claims with Medicare, Always ask for a review and a
fair hearing. The only requirement is that the disputed claim or aggregate
claims total more than $100.00 in dispute. Good Luck. I'll bet that you'll
be amazed at you percentage of Fair Hearings that will be decided in your
favor! Just have all of your ducks in a row but remember, when that patient
comes back for high top shoes again, don't accept the assignment or you'll
have to go through the same routine. Winning a Fair Hearing does not set a
precedent!



Here is some info. on shoes...
1. L3222 is a valid code and should be covered if the shoe is attached to a
brace and if the high top is medically necessary for the brace to function
properly. See the Orthopedic Shoe medical policy in your Medicare Supplier
Manual, under Coverage and Payment Rules, 2nd paragraph. Also take a look
at Coding Guidelines and Documentation sections of this policy, which also
speaks to using the repair codes.
    2. In general, Medicare doesn't usually pay labor on top of another L
code.
They expect all costs for supplying an item to be included in the charges
for the L codes that describe it.
    3. For a shoe attached to an orthosis, you need to do two things...use the
ZX modifier with the L code, and document in your records that the shoe was
attached to a brace. You don't need to fill out any separate CMN. The ZX
modifier says to the DMERC that you have met the criteria of the code (that
the shoe is attached to the brace) and that you have documentation in your
records to support that.
    4. This answer would probably be best given by your fellow practitioners,
but in general, I would say that based upon the feedback I get doing the
Coding & Billing Seminars, many people do not accept assignment on shoes.
    By the way, you cannot artificially split a claim in two, and take
assignment on one and not on another. Treatment/services on one date of
service must be either all assigned or non-assigned.

Kathy Dodson

In NY It has been our experience that Medicare will only pay for shoes
if the patient is diabetic (use A shoe codes and modifiers RT LT ZX) or
if the shoe is attached to a brace . Medicare will ONLY pay for the shoe
that is attached. use code L3224 or L3225 and modifier RT or LT and ZX to
indicate attached to brace. You can also use transfer codes if applicable
(L3600 to L3649). The other shoe is billed with a regular shoe code and a
Rt or Lt modifier and a ZY to indicate that it is non-covered. They
require a CMN for diabetic shoes, but not for shoes attached to an
orthosis (Rx is sufficient) Other than these, we have very little success
billing Medicare for any other shoe items. In most cases, we do not
accept assignment because their allowable is too low. (we are
nonparticipating, so we have that option) to protect yourself, you can
also use a GA modifier and have the patient sign a waiver that states
that you have explained that something might not be a covered service and
they will be responsible for payment. In all of my literature L3222
hightop shoe has always been listed as a non-covered item so I wasn't
sure how you were getting L3222 paid in the past.
If you are participating with Medicare, you do not have the option of not
accepting assignment on covered services.
All of the adjustments are included in the price for the initial item for
the first 60 days. After that, we use the L4205 code for orthotic
adjustment but again, only applicable to those items
initially covered by Medicare.
    Again, this is what we are restricted to in NY... Hope this has been of
some help