Part 1-Responses to coding dilemma

Part 1-Responses to coding dilemma

Michael P Madden

4/4/2002

Thanks to all who replied per my original post. Though I was told in
a sideline conversation with a member of the coding committee at the
Las Vegas coding seminar that I was correct in my inclusion of the L2435,
I have had no official response from the coding committee, or G II.

Replies:
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Unfortunately the dj Orthopedics and GenII reps have messed you up. I
don't think that they know about the add on codes, just the base
codes,therefore they only bill for the base code. I bet if they knew
what the additions were and found out that they can charge for them, they
sure would do it. Give them the scenario of the L1970. The Medicare
description is AFO w/hinged ankle, but you add the ankle joints. If you
are asking for additional components to be put on your KO's, you have
every right to bill for them, since the company will bill you for them.
The problem is bundling. I think that there are more and more people out
there that are bundling all there codes and prices into the base code, so
that they do not have to deal with what you a dealing with right now. I
say keep trying and see if you can get some documentation from your
Medicare carrier and show the insurance carrier that what you are doing
is legal and correct. You might want to let the sales reps know what is
going on, and that you have them to thank for your headaches.
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We have also gone through, and continue with the same dilemma. Including
the DJ, and other reps billing at base code only. We have also been
accused of unbundling codes and have gone round and round up through
the powers
that be. We now take the approach with devices that are prescribed by
brand name that unless they are SPECIFALLY identified in the L codes
descriptions we are now using an UNLISTED code. The exceptions are l1858
which lists the CTI and L1846 which identifies the Lennox Hill in the
Medicare descriptions. NO other knee brace is specifically identified.
L1844 does not identify the GII specifically by brand but by function.Our
approach has been to bill the unlisted code with the brand name of the
devcie as the descriptor. We then attach a cover letter that explains the
use
of the unlisted code and list ALL of the L codes that would be used in
constructing the same devcie seperately. We have had very little
resistance to date. They understand that the L codes describe GENERIC
devices.(use the Rx drug comparison) We are being paid based upon UC
billed charges on the unlisted codes with little ability for comparsion
to L code allowables.To date we have not had one of these downcoded or
the coding altered by the payor. It seems to limit the reps from selling
direct as well.
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Hi Michael- You're on the right track with your thinking. You ought to
be on the L coding committee, but at least you should be in touch with
them. They've been through this battle already and might have info. to
help you.
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Questions to bring forth to the insurance company:1) Are the reps
certified/licensed practitioners?2) Do they carry malpractice
insurance?3) Medicare requires providers of orthoses/prostheses to have
an on-site visit. Where is their site? Has it been approved?4) What is
their educational level? Have they received a degree in the pathologies
necessary to adequately treat the patient?5) Why doesn't the insurance
company just stock up directly from the
manufacturer and mail the items to the patients? It would be just as
cheap with about as good a service!!
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Hi, In my humble opinion, you are entirely correct. Bill for what you
provide and don't bill for what you don't provide whether the item is
made in house or elsewhere. According to the ins.company's logic, any
time you used central fabrication you would only be allowed to use the
base code!! (That would sure cut down on use of central fab for
prosthetics) Please stick to your guns on this one! As far as the
manufacturer's reps goes-and that's another can of worms- they should be
billing for the add-on codes as well, they're just undercutting because
they can afford to; they're not paying the cost that we're paying for the
items. Keep at it - maybe we'll get paid what we're entitled to some day
(doubtful, but hey - you have to have hope).
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Mike, I'm with you bigtime.If a provider code does not accurately
describe the orthosis delivered, whether over-coded or under-coded, the
provider has committed an error. The description codes used are just
that, descriptions attached to a
convenient code to allow insurance payors to understand what was provided
to their member. Essentially, the payor asking you to not accurately
describe the device would be the same as you walking into a car
dealership and asking the salesman to not list all the options included
from the manufacturer to reduce the price. As far as GII not recommending
the L2435 code, our rep said that the joint provided is not poly-centric,
it's poly-axial. I think it's both.
We have had insurance companies call other providers in the area and
compare notes as to which codes should be used and then boil it down to
the lowest common denominators as to the codes they will pay for. The
payors haven't
specifically listed the companies they've contacted. Our argument is,
let the other companies under-code and in doing so, miss-bill the
insured. Just don't expect a custom ordered, fully loaded Lexus to be
billed as a Toyota.
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Hi Mr. Madden, I wonder if Don Joy and CTI cut the same deal with the
government. It seems that if they do not need to use the additional
codes when billing the insurance companies, they shouldn't need those
codes when billing medicare. I would ask for a letter outlining the deal
the insurance company made with the brace manufacturers. That letter
could cost the brace manufacturers a fortune if my thinking is correct.
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Typical insurance company smoke screen to avoid paying. Using their
logic, they should not pay DonJoy and CTi the base code
reimbursement.Obviously, their cost to manufacture the brace is probably
less than half your cost. Logically, they should then only pay a small
markup above their actual manufacturing cost. Let them ask DonJoy and CTi
what it cost them to make that brace, and then let the insurance company
reimbursement using that criteria.......yea right...that will never
happen!!. I'm sure they (DonJoy, CTi) cannot justify a cost anywhere near
the insurance reimbursement! My $.02
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Mike, I personally feel you are on solid ground and that the inclusion
of the add-on codes are appropriate. I am disappointed once again in the
Don Joy and Cti reps and wish there were some way our profession could
undercut
them like they have done to us. That's another issue, however. Try to
contact the national office and speak to Kathy Dodson for documentation
on the appropriate use of L codes. A good analogy to use with these
insurance
companies would be a new car. Options and accessories can be
included,but at additional cost. Or you may have the Model T. Best
wishes. This is a frustration for us all.



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