Medicare reimbursement Dynamic orthoses RESPONSES
Randy McFarland
Description
Collection
Title:
Medicare reimbursement Dynamic orthoses RESPONSES
Creator:
Randy McFarland
Date:
8/16/2006
Text:
ORIGINAL POST
I have a post total knee replacement patient who lacks full flexion
and extension range of motion. UltraFlex instructs me to use total knee
replacement as the diagnosis (and not contracture) and to use L1832
as the base code, but I read Medicare's information to say that code
can't be used for contractures but L1831 can be. (Custom fabricated is
not needed for her leg contour)
Any pointers on the feasibility of billing Medicare for this type of
orthosis? It appears that rental is the only way. If you've had success
with selling this type of orthosis, please let me know. Randy McFarland,
CPO, Fullerton, CA
RESPONSES
I have learned after having been instructed by Bill @ Ultraflex not to
use the term contracture. To medicare and other third party payers a
contracture is permanent with the only option for correction being
surgery. Using the clinical description of failure of soft tissue to
elongate will, and has, produced significantly fewer denials.
I was denied a claim by Medicare because a contracture can only be
surgically released. According to Medicare, an orthosis will assist
with a restricted range of motion. After eating 2 Ultraflex kafo's, I
stopped using them and left the Medicare patients to find a way to rent
a KAFO. I will never used the word contracture in any diagnosis code
or any other written communication with Medicare.
Just yesterday I ran into the same issue. In fact, if it weren't for the
fact you're in Fullerton and I'm in Oxnard, I would have wondered if it
wasn't the same patient/case.
A while back, I had problems billing Medicare for a purchase of a
dynamic
orthosis that was intended to be used for a limited time. If Medicare
doesn't agree to a purchase, what's the rental HCP code?
Please tell your patient that Medicare will not pay for the joints,
(good luck). Why they will not pay for a dynamic hinge is beyond
stupidity. Its really the best way to treat the diagnosis. I have billed
the patient privately for the hinge( the dynamic part only. I billed
Medicare for the rest including the adjustable flex/extension code.
It seems to me that Medicare has very specific rules on contracture
diagnoses and have you using rental E codes for off the shelf orthoses.
We have been using the contracture braces from Ortho innovations and I
know they have been in contact with Medicare about the proper coding. In
reference to your original message I didn't think there was a knee
replacement diagnosis as this is really a surgical procedure and
therefore the diagnosis would actually be contracture. We also are
scratching our heads on the right way to do this. I don't think Medicare
even is sure. I'm sorry about not being much help, just know you are not
alone!
I just had a similar situation. I advised the insurance company that we
contract with that they could either purchase the system from us or we
would agree to them renting the unit directly from Dynasplint. There
really doesn't seem to be a way around Medicare's requirement that this
type of orthosis be rented, not purchased.
Rental was only option in our case so we took a pass on treating
patient.
Medicare has tied our hands. I see no way to earn profit on these
splints with the rental, and I think that's the only way to bill
correctly. If you come across a different solution that's within the
Medicare coding guidelines, please let me know.
I have learned after having been instructed by Bill @ Ultraflex not to
use the term contracture. To Medicare and other third party payers a
contracture is permanent with the only option for correction being
surgery. Using the clinical description of failure of soft tissue to
elongate will, and has, produced significantly fewer denials.
I have a post total knee replacement patient who lacks full flexion
and extension range of motion. UltraFlex instructs me to use total knee
replacement as the diagnosis (and not contracture) and to use L1832
as the base code, but I read Medicare's information to say that code
can't be used for contractures but L1831 can be. (Custom fabricated is
not needed for her leg contour)
Any pointers on the feasibility of billing Medicare for this type of
orthosis? It appears that rental is the only way. If you've had success
with selling this type of orthosis, please let me know. Randy McFarland,
CPO, Fullerton, CA
RESPONSES
I have learned after having been instructed by Bill @ Ultraflex not to
use the term contracture. To medicare and other third party payers a
contracture is permanent with the only option for correction being
surgery. Using the clinical description of failure of soft tissue to
elongate will, and has, produced significantly fewer denials.
I was denied a claim by Medicare because a contracture can only be
surgically released. According to Medicare, an orthosis will assist
with a restricted range of motion. After eating 2 Ultraflex kafo's, I
stopped using them and left the Medicare patients to find a way to rent
a KAFO. I will never used the word contracture in any diagnosis code
or any other written communication with Medicare.
Just yesterday I ran into the same issue. In fact, if it weren't for the
fact you're in Fullerton and I'm in Oxnard, I would have wondered if it
wasn't the same patient/case.
A while back, I had problems billing Medicare for a purchase of a
dynamic
orthosis that was intended to be used for a limited time. If Medicare
doesn't agree to a purchase, what's the rental HCP code?
Please tell your patient that Medicare will not pay for the joints,
(good luck). Why they will not pay for a dynamic hinge is beyond
stupidity. Its really the best way to treat the diagnosis. I have billed
the patient privately for the hinge( the dynamic part only. I billed
Medicare for the rest including the adjustable flex/extension code.
It seems to me that Medicare has very specific rules on contracture
diagnoses and have you using rental E codes for off the shelf orthoses.
We have been using the contracture braces from Ortho innovations and I
know they have been in contact with Medicare about the proper coding. In
reference to your original message I didn't think there was a knee
replacement diagnosis as this is really a surgical procedure and
therefore the diagnosis would actually be contracture. We also are
scratching our heads on the right way to do this. I don't think Medicare
even is sure. I'm sorry about not being much help, just know you are not
alone!
I just had a similar situation. I advised the insurance company that we
contract with that they could either purchase the system from us or we
would agree to them renting the unit directly from Dynasplint. There
really doesn't seem to be a way around Medicare's requirement that this
type of orthosis be rented, not purchased.
Rental was only option in our case so we took a pass on treating
patient.
Medicare has tied our hands. I see no way to earn profit on these
splints with the rental, and I think that's the only way to bill
correctly. If you come across a different solution that's within the
Medicare coding guidelines, please let me know.
I have learned after having been instructed by Bill @ Ultraflex not to
use the term contracture. To Medicare and other third party payers a
contracture is permanent with the only option for correction being
surgery. Using the clinical description of failure of soft tissue to
elongate will, and has, produced significantly fewer denials.
Citation
Randy McFarland, “Medicare reimbursement Dynamic orthoses RESPONSES,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/227094.
