Replies to "medicare Denials" question

Replies to "medicare Denials" question

MKShop

12/8/2003

Original Question

We are a region C Medicare provider and are getting denials from Medicarebecause they say the patient has received a like or similar device. We wereaware of the change coming and had the patient sign the appropriate form andfiled with the appropriate modifiers that said we knew it may be denied.More often than not the patient received a walking boot, CAM walker if youprefer. Very often physicians will prescribe these for the short term,then, if appropriate, an AFO for long term use. Medicare then denies the
AFO due to the patient possessing the boot.

I recently sent an appeal letter and have yet to hear back. I was wonderingif all are having this problem and if any of you have had success on appeal.If you did, may I ask how you justified your appeal.

Any help would be appreciated. I will post replies with names omitted for those who may be interested. Thanks.

Kevin C. Matthews, CO/LO

Below are the responses
This problem is most likely due to the fact that many stock and bill programs and DME providers are billing for these walkers using L1930. For those of you who are not aware, many companies are also billing these
walkers out using L2112, L2114 and L2116 (Sarmiento type fracture orthoses) just because the diagnosis includes the letters fx. This practice is rampant.

We have had a number of similar cases which is very frustrating. Even after appeal,most were denied with no recourse to bill the patient. I am beginning to think we need to have all our Medicare paients sign waivors now

we have had denials---have a 90% + success rate with appeals with lomn and following guidelines

I would want to know what codes the physician filed under. I know that some offices were using incorrect billing codes for walkers. Some companies listed incorrect codes in their catalogs eg DonJoy and Breg, and I would suspect that not all offices have corrected the error. I would suspect that the office billed for a L19? instead of a L43 code.

Let me know what you find out.

We have this situation on almost a weekly basis. It has gotten to the point that when we send in for the review it hardly ever goes to hearing. We won the ones that did go to hearing. We request reviews and hearings on the same basis: The Walker Boot is the first step in the healing process. The AFO, or whatever, is the next step.

We justify our position by demonstrating that the two items are not similar because they are being used for different functions, and further clarify by providing testimony that the reason for changing from one design to the other is because of a change in the patient's physical condition(Social Security Act, Section 1834[h]). The supporting section of
The Act is 1861(s)(9), and is additionally strengthened by 42 CFR 414.202 of the Code of Federal Regulations (p. 637).

Here is a link to the specific language:
  <URL Redacted>
This particular document is from 1996, but the language hasn't changed.

Here is a link to the Region C carrier's manual:
<URL Redacted>
54852566B30053F871?OpenDocument

Hope this helps.

Appeal them all Kevin. you'll have to get the doctor's or the OR's medical records, but they will give you your money on appeal. While you're at it explain to them that DME items should have seperate code designations and doctors and other health care professionals should not use L-codes. It will fall on deaf ears but eventually someone with a little sense will realize that it is not the O&P community who exploit CMS.

Correction on the web links:

<URL Redacted>

http://www.palmettogba.com/palmetto/providers.nsf/Attachments/85256D580043E7
54852566B30053F871?OpenDocument

We had a similar situation. A patient was fit with a CROW boot for diabetic complications. Following 2-3 months she was ready to be fit with a lesser type of AFO, a custom leather ankle gauntlet AFO. Medicare denied claim for same or similar. We appealed and asked for a hearing. We submitted pictures of the two devices for the hearing officer to review while we explained the treatment protocol. Pictures are very very important. You have to focus on the fact that the patient's diagnosis changed, or the condition changed, and you were treating the prescribed dx. In my opinion, you have to focus on the change in the patients condition and use pictures. By the way, we won the denial.......

Yes, we have had that similar problem. Pt receives a cam walker, billed at L 2112, from a physician and then get prescribed an AFO. We won one appeal and I can't remember on the last. It's a problem though. If the patient has any type of device from another source, we get an ABN signed.

We also have a problem with pt's lying about when they recieved diabetic shoes from other sources. Medicare expects us to be able to tell when patients got shoes from somewhere else. We haven't figured out how to do that yet. Is there an L-code for a polygraph examination?




We have appealed several of these before we became fully aware of the ramifications of this policy. We were not successful in convincing Medicare that we had no way of knowing that the claim would not be paid. The moral of the story for us at least is protect yourself and your patient by full disclosure. If there is a hint of a doubt that the serivce will be covered we have the patient sign a waiver.

Hope this helps. I would be very interested in a summary of the responses that you receive on this issue.

Good luck to us all!!!
Good Luck---I've gone through a number of appeals myself,under similar circumstances...Seems as though they are just wanting to hold your money for another
30-60 days....
As for the appeal, as long as you can justify the scenario or the circumstances , of why you did this and that, and also back that up with the Physicians notes, you will be fine.....It is the delaying of the money, that hurts the
small business person...This problem is most likely due to the fact that many stock and bill programs and DME providers are billing for these walkers using L1930.
For those of you who are not aware, many companies are also billing these walkers out using L2112, L2114 and L2116 (Sarmiento type fracture orthoses) just because the diagnosis includes the letters fx. This practice is rampant.

It seems we can get paid on appeal if the patient's condition changes or the physician's note justifies the change. Since this question was answered I have appealed 3 more denials. What a major pain! As if there wasn't enough to do!
Thanks to all those that responded, and as one person stated so eloquently, Appeal them ALL!!!

Kevin Matthews CO/LO