Part 2 responses to coding dilemma
Michael P Madden
Description
Collection
Title:
Part 2 responses to coding dilemma
Creator:
Michael P Madden
Date:
4/4/2002
Text:
Only L1858 should be used for all Custom KOs made and ANY company, except
L1844 can be used for Generation II. NO ADD ON CODES should be used as
all add ons are inclusive in the base codes. You can add on L2755 to
the
Generation II orthoses as the original L code had polyethylene cuffs. The
only way you could us the other add on codes, if you manufactured the
orthosis in your own laboratory. Any changes will need to come from the
KO manufacturers by obtaining new codes from the SADMERC. What you are
missing is the original code defined a specific product and that still
determines the add on potential. Hope this helps.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, You are correct in the inclusion of these 'add-ons' for the
manufactured items. It seems to me that there should be no difference
between the items made in your lab or someone else's lab. Unfortunately,
the reps are not doing this for our benefit...They make the same
commission for a sale whether I fit it or they fit it. I cannot and will
not fit a Gen II
Custom for the base code; I will lose money on that deal. If you are
interested in a race to the bottom, then have at it. I strongly
recommend that you take the AOPA Coding Seminar to clear up these issues.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
First KUDOS to you for fighting for what is rightfully yours. Insurance
companies have way too much power over what we bill for and what we
don't. You are justified in billing for those add on codes as per the
description of each code. DJ and CTi get away with base billing because
they have noother costs involved. They have no middle man. Insurance
companies should be checking out their (DJ CTi) credentials and asking
for copies of accreditation, trading license, certification for O & P,
and liability insurance forms. They ask us as providers for these items.
Ours is not an easy fight if we are not careful we can loose referrals.
It is easy to say lets Boycott DJ and CTi but Everyone would have to
agree and that will probably never happen. Maybe our industry
organizations ( AOPA, IAOP,etc.) could help by not allowing them at
conventions but that would mean loss of revenue for them. What your doing
is right and I hope you continue. I
wish you luck, I have been there myself and sometimes the outcome has
been favorable. I do know that HCFA is currently working on new regs for
O & P and maybe by the end of the year we will not have to be in direct
competition
with manufacturers.Good Luck,
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hi Mr. Madden.I am currently going through the exact scenario that you
are describing. My case was with a DJ knee orthosis regarding the use of
the polycentric knee joint code. I was able to obtain a letter from Don
Joy that stated that
the orthosis is manufactured with polycentric joints. (Don Joy only
recommends the base code.) I have had many discussions with Don Joy
asking them to either recommend all of the applicable codes, or to make
no recommendations at all, leave the coding to the responsible
practitioner. I was told that this has been the source of headaches for
them, and that they are considering not recommending any codes. At this
point, the fraud and abuse person with the insurance co has said that I
was right with my coding and to proceed with billing the patient for his
portion. But my problem does not end here. The patient does not
understand how one knee orthosis can possibly have four joints, and
refuses to pay his portion. If I write off this balance, it is like
admitting guilt. BUT, he is threatening the insurance co with the
insurance commissioner, and I enjoy a good relationship with this
insurance co. I have already lost a lot of $$ with administrative costs
fighting this, and I don't think it's over yet. Worse,from what you say,
I'm now afraid that I will be fighting the same battle with more
insurance companies.My best thought is that it's time to provide knee
orthoses that come from manufacturers who understand how coding works,
and will support us in our battles for reimbursement. Using products
from DJ and CTi and others,who compete with us by selling directly and
billing their products using incomplete coding, just continues to hurt
us. I am now afraid to use anything but the manufacturers recommended
codes, and therefore am in the process of selecting new products based on
some of these issues (as long as I can find equal quality). I am
interested to know if you think that we can
educate the third party payors or if you think that they all will play
dumb in order to get away with paying less? How do you plan to deal
with the ones that we cannot educate?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike, First if your coding for a specifically defined orthosis from
the L-codes concerning specific knee orthoses then the insurance company
happens to be correct in assuming you are unbundling the parts. For
example you
cannotby a CTI orthosis with a different knee joint than polycentric so
you can't break out the joints seperately. On the other hand if the
orthosis is being made to specification like a Townsend then you are able
to bill for the specific
requirements of the orthosis. In the case of companies direct billing
using only base codes, you will almost never win. The charges to you do
not allow you to provide the brace and service for the reimbursment rate.
Unless you hae a really good relationship with a rep your fighting an up
hill battle. If you have a good relationship with your doctors have them
go to a completely generic prescription. This would allow you to provide
the orthosis with all of the add ons prescribed. If your doctors are not
willing to change then try discussing it with the companies. Finally be
careful when attempting to unbundle codes especially with orthoses that
are described in the L-codes that's where you walk the fraud and abuse
line.GOOD LUCK WITH YOUR QUEST.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike,This is just one more example of the field getting away from
the practitioners. It is extremely frustrating. We are getting pulled
into 'tug of wars' in many areas and my simplest strategy has been to let
go of the rope. I just won't play around with them. The way I see it,
if they want to pay for a base code item, I'll give them a base code
product. I'll pay less and they'll pay less. If they want bells and
whistles, they are just going to have to pay for it. Even if the product
comes with the extras, I end up paying a higher price for the upgraded
item than I would for base code item. We are not doing ourselves or the
industry any favors by caving.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I have positioned myself as a specialist. I go the extra mile and make
sure everything I do is proper and effective. My patients, my doctors
and I know it. If the insurance companies don't see it that way, I tell
them to go to another facility. If the other facility wants to do it at
a cut rate price, they'll end up paying for it initially but, inevitably,
we all end up
paying for it. My stance was difficult at first, but I want to assure
you that it is working more and more every day. Believe me, the
physicians that refer us the work know the difference between facilities
that are a good value and facilities that offer 'low-ball' rates. They
want a good value (excellent service and products at a fare price). If
we all take this stance, they will have no choice but deal with us as
respectfully as we carry ourselves in our profession. Although we are all
each others competition in one way, we don't have to be unhealthy
competitors. We must be healthy competitors, competing in quality and
service, not in price. Mike, I want to urge you to fight the good fight
and keep the faith.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
you are only off your rocker if the add ons are artifically inflating
your reembursement. It has been the problem for some years that this has
been the case. Our profession needs to be very careful not to be too
greedy or creative or there
will be more repercussions then already exist.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, I agree with your logic in this coding situation. The orthosis
with a polycentric joint costs you more than if you bought the same
orthosis with a single axis joint. That is what the coding system
accounts for. Good luck.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike:You may want to approach the insurance company from a cost analysis
perspective. You know your business and what it takes to keep it
solvent. For instance, if you spend 30% of company income on payroll and
employee expenses, 30% on general overhead (electricity, mortgage or
lease, equipment, etc.), 30% on actual component costs, and maintain a
10% profit...then you can back into justification of charges using your
formula. Accordingly, if the total cost of components in question is
$500, an equal amount should be added for payroll and overhead to provide
the service along with the 10% for your profit. This brings the
justifiable charge for the service to about $1670...$500 for components
(30%), $500 for overhead (30%), $500 for employee expenses (30%), and
$167 for profit (10%). Of course, you use whatever formula fits your
business. This is just one example of the cost analysis concept. You may
have an easier time justifying your charges if you have a concrete
formula for determining expenses, rather than trying to justify based on
the arbitrary consideration of charges you assume to be rolled in by the
manufacturer. Of course it depends on the people you are negotiating
with.Good luck.
________________________________________________________________
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Join Juno today! For your FREE software, visit:
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L1844 can be used for Generation II. NO ADD ON CODES should be used as
all add ons are inclusive in the base codes. You can add on L2755 to
the
Generation II orthoses as the original L code had polyethylene cuffs. The
only way you could us the other add on codes, if you manufactured the
orthosis in your own laboratory. Any changes will need to come from the
KO manufacturers by obtaining new codes from the SADMERC. What you are
missing is the original code defined a specific product and that still
determines the add on potential. Hope this helps.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, You are correct in the inclusion of these 'add-ons' for the
manufactured items. It seems to me that there should be no difference
between the items made in your lab or someone else's lab. Unfortunately,
the reps are not doing this for our benefit...They make the same
commission for a sale whether I fit it or they fit it. I cannot and will
not fit a Gen II
Custom for the base code; I will lose money on that deal. If you are
interested in a race to the bottom, then have at it. I strongly
recommend that you take the AOPA Coding Seminar to clear up these issues.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
First KUDOS to you for fighting for what is rightfully yours. Insurance
companies have way too much power over what we bill for and what we
don't. You are justified in billing for those add on codes as per the
description of each code. DJ and CTi get away with base billing because
they have noother costs involved. They have no middle man. Insurance
companies should be checking out their (DJ CTi) credentials and asking
for copies of accreditation, trading license, certification for O & P,
and liability insurance forms. They ask us as providers for these items.
Ours is not an easy fight if we are not careful we can loose referrals.
It is easy to say lets Boycott DJ and CTi but Everyone would have to
agree and that will probably never happen. Maybe our industry
organizations ( AOPA, IAOP,etc.) could help by not allowing them at
conventions but that would mean loss of revenue for them. What your doing
is right and I hope you continue. I
wish you luck, I have been there myself and sometimes the outcome has
been favorable. I do know that HCFA is currently working on new regs for
O & P and maybe by the end of the year we will not have to be in direct
competition
with manufacturers.Good Luck,
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hi Mr. Madden.I am currently going through the exact scenario that you
are describing. My case was with a DJ knee orthosis regarding the use of
the polycentric knee joint code. I was able to obtain a letter from Don
Joy that stated that
the orthosis is manufactured with polycentric joints. (Don Joy only
recommends the base code.) I have had many discussions with Don Joy
asking them to either recommend all of the applicable codes, or to make
no recommendations at all, leave the coding to the responsible
practitioner. I was told that this has been the source of headaches for
them, and that they are considering not recommending any codes. At this
point, the fraud and abuse person with the insurance co has said that I
was right with my coding and to proceed with billing the patient for his
portion. But my problem does not end here. The patient does not
understand how one knee orthosis can possibly have four joints, and
refuses to pay his portion. If I write off this balance, it is like
admitting guilt. BUT, he is threatening the insurance co with the
insurance commissioner, and I enjoy a good relationship with this
insurance co. I have already lost a lot of $$ with administrative costs
fighting this, and I don't think it's over yet. Worse,from what you say,
I'm now afraid that I will be fighting the same battle with more
insurance companies.My best thought is that it's time to provide knee
orthoses that come from manufacturers who understand how coding works,
and will support us in our battles for reimbursement. Using products
from DJ and CTi and others,who compete with us by selling directly and
billing their products using incomplete coding, just continues to hurt
us. I am now afraid to use anything but the manufacturers recommended
codes, and therefore am in the process of selecting new products based on
some of these issues (as long as I can find equal quality). I am
interested to know if you think that we can
educate the third party payors or if you think that they all will play
dumb in order to get away with paying less? How do you plan to deal
with the ones that we cannot educate?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike, First if your coding for a specifically defined orthosis from
the L-codes concerning specific knee orthoses then the insurance company
happens to be correct in assuming you are unbundling the parts. For
example you
cannotby a CTI orthosis with a different knee joint than polycentric so
you can't break out the joints seperately. On the other hand if the
orthosis is being made to specification like a Townsend then you are able
to bill for the specific
requirements of the orthosis. In the case of companies direct billing
using only base codes, you will almost never win. The charges to you do
not allow you to provide the brace and service for the reimbursment rate.
Unless you hae a really good relationship with a rep your fighting an up
hill battle. If you have a good relationship with your doctors have them
go to a completely generic prescription. This would allow you to provide
the orthosis with all of the add ons prescribed. If your doctors are not
willing to change then try discussing it with the companies. Finally be
careful when attempting to unbundle codes especially with orthoses that
are described in the L-codes that's where you walk the fraud and abuse
line.GOOD LUCK WITH YOUR QUEST.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Mike,This is just one more example of the field getting away from
the practitioners. It is extremely frustrating. We are getting pulled
into 'tug of wars' in many areas and my simplest strategy has been to let
go of the rope. I just won't play around with them. The way I see it,
if they want to pay for a base code item, I'll give them a base code
product. I'll pay less and they'll pay less. If they want bells and
whistles, they are just going to have to pay for it. Even if the product
comes with the extras, I end up paying a higher price for the upgraded
item than I would for base code item. We are not doing ourselves or the
industry any favors by caving.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I have positioned myself as a specialist. I go the extra mile and make
sure everything I do is proper and effective. My patients, my doctors
and I know it. If the insurance companies don't see it that way, I tell
them to go to another facility. If the other facility wants to do it at
a cut rate price, they'll end up paying for it initially but, inevitably,
we all end up
paying for it. My stance was difficult at first, but I want to assure
you that it is working more and more every day. Believe me, the
physicians that refer us the work know the difference between facilities
that are a good value and facilities that offer 'low-ball' rates. They
want a good value (excellent service and products at a fare price). If
we all take this stance, they will have no choice but deal with us as
respectfully as we carry ourselves in our profession. Although we are all
each others competition in one way, we don't have to be unhealthy
competitors. We must be healthy competitors, competing in quality and
service, not in price. Mike, I want to urge you to fight the good fight
and keep the faith.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
you are only off your rocker if the add ons are artifically inflating
your reembursement. It has been the problem for some years that this has
been the case. Our profession needs to be very careful not to be too
greedy or creative or there
will be more repercussions then already exist.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike, I agree with your logic in this coding situation. The orthosis
with a polycentric joint costs you more than if you bought the same
orthosis with a single axis joint. That is what the coding system
accounts for. Good luck.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mike:You may want to approach the insurance company from a cost analysis
perspective. You know your business and what it takes to keep it
solvent. For instance, if you spend 30% of company income on payroll and
employee expenses, 30% on general overhead (electricity, mortgage or
lease, equipment, etc.), 30% on actual component costs, and maintain a
10% profit...then you can back into justification of charges using your
formula. Accordingly, if the total cost of components in question is
$500, an equal amount should be added for payroll and overhead to provide
the service along with the 10% for your profit. This brings the
justifiable charge for the service to about $1670...$500 for components
(30%), $500 for overhead (30%), $500 for employee expenses (30%), and
$167 for profit (10%). Of course, you use whatever formula fits your
business. This is just one example of the cost analysis concept. You may
have an easier time justifying your charges if you have a concrete
formula for determining expenses, rather than trying to justify based on
the arbitrary consideration of charges you assume to be rolled in by the
manufacturer. Of course it depends on the people you are negotiating
with.Good luck.
________________________________________________________________
GET INTERNET ACCESS FROM JUNO!
Juno offers FREE or PREMIUM Internet access for less!
Join Juno today! For your FREE software, visit:
<URL Redacted>.
Citation
Michael P Madden, “Part 2 responses to coding dilemma,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 7, 2024, https://library.drfop.org/items/show/218885.
