Region C helps Region A

Region C helps Region A

Kim Edgar

5/6/2004

Here is a list of responses that I received. Hope this helps everyone as it helped me.

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what codes are you using? are you getting any medical necessity documentation requests? Region C is currently going through probe audits and we are in Region C.
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It is the new rule deny everything. LOLYoull need to send Medical records
for the date the Rx was written, and a prior visit as well. Progress notes
to show progression of the disease which requires bracing. Letter of
medical nessity, with diagnosis, bracing prescribed, length of time braceing
required, and reason why custom fabricated is required.
It gets worse we have to do this for every custom device we fit!!! We have
stoped taking assingment on any custom device. We file for the patient and
even file apeals but we are a small company
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Kim we have had similar denials from region B. When I call them they
tell me I need more numbers in the ICD9 diagnosis code. They want a 5
digit number not just a 4 digit number. Get a new ICD9 code book, the
new numbers are in the latest version. Good luck
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We are haveing a terrible time. Please post any help you get. Thank you
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What are all of the codes associated with your denials, i.e.: MA13, M81,
MA130, CO96, etc.? Region C certainly has been picky lately!
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get in touch with your ombudsperson and have them research it - in
Region A it turned out the claims were missing one or two items that were
never required in previous years so they got rejected entirely. If you are
doing paper claims or electronic it matters how you fill things out. Also,
did you try calling claims to ask them
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If you billed Region C and claim was denied for lack of information it
usually means they believe the patient received a similar device within the last 5
years. They want to know why the patient needs a new device to determine
whether these services should be covered (see 5-year rule for orthotic devices).
If you file electronic claims you can submit this info with the claim,
otherwise you have to submit a review request with all your documentation. Call me
if you need more info.
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Basically,you can give the best documentation ,physician's notes,pictures of the braces,testimonials of the patient and PTs,detailed fabrication notes and invoices on each thing that was used in the casting to construction and to fitting of this device and you will never get paid.You will get nice letters from CMS that say you need this and that and still we more than likely won't pay the bill.You have no choice but to call it a loss.Don't give up billing or start using off the shelf,that is what they want you to do.This is a ploy to make all of our coding a base code with no options type settings.One stop shop for bankruptcy.I personally make it a goal of mine to provide each patient with the proper device for the situation but now the only thing I can do is explain how I can't give them what they are used to because it might send me to the cleaners.Try,never give up,something will have to be done and maybe we might come out employed.If we had proper representation,our field wouldn't need email like this ,we would be getting the increases of the PTs and MDs.I guess we have to hire their lobbyists to get anything done and let ours stay focused on the alphabet wars.Good luck,you are going to need it.
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That was all my replies, thanks again to all that responded.

Kim Edgar,
Office Manager