Summary- US-policy CMS denial

Summary- US-policy CMS denial

Gary Berke

6/18/2009

Summary of the responses to the US-policy CMS denial of C-Leg repair. We
will be resubmitting with new codes listed below.. Hope it works! Thanks to
all who offered thoughts and suggestions!

 

Here is the original post:

 

We have received several denials from Medicare on the repair of a C-Leg. The
prosthesis was paid for by CMS and is now out of warranty. The latest cost
to repair was approximately $5000. We have billed under 7510-RP. CMS stated
that the 7510 (replacement of minor parts) has a maximum number of units of
4 units. Unfortunately it takes more than 4 units to achieve the 5000. cost
for the repair.

 

Some of the Responses: (not all responses were directly related to Medicare)


 

our understanding from Otto Bock is that in July 2008 Otto Bock instituted a
price cap on repair charges in the amount of $3,000 for repairs between the
3rd year and 4th year and $4,300 for repairs between the 4th and 5th years.

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Depending on what was fixed on the C-leg we have used:

 

L5828 with modifiers of (LTRPK3)

L5856 with modifiers of (LTRPK3)

L7367 with modifier (RP)

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One thing that I see is that CMS has changed the modifier to RB. So it
should read L7520 (x your units) (your actual evaluation and lab time which
should also be documented in the chart) it should be broken down..i.e. 20
minutes evaluating the problem, and 6 hours repairing (whatever repair was)
in lab(example only). As well as L7510 RB, (narrative to include whatever
the minor part was) Be very specific in your notes as to the repair that was
done. If any other parts were changed..i.e. locking mechanism. You may use
the actual L code as long as the repair labor units did not include
replacing the locking mechanism.

Just for clarification an example of proper billing would be

L7520 rt/lt (which ever) number of units utilized.

L7510 rt/lt RB x 4 units... add pricing

must also utilize the narrative field to include the meat of what you
repaired

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The replaced battery was billed using L7367 RP (rp was the modifier used
last year; use this years version); L5828 LTRPK3 for repairs to the
hydraulic unit and L5856 LTRPK# for repairs to the knee. Electronically
submitted, it took Medicare three weeks to approve and pay this claim after
5 rejections using the labor and replace minor parts. Except for the
battery (which has a predetermined allowable), Medicare allowed my full
fee!!!

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I use a L5999 code -repair no labor

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Bill L 7510 RP for 4 units on one line then again and again on different
lines.

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The best advise I can give you is to have the patient get the extended
warranty on there C Legs. Although it costs the patient up front the
warranty extension covers the knee till the end of the five year Medicare
replacement requirement. The other option is to do a replacement based
request, based on the cost to replace vs a new prosthesis. If you go to
appeal it may have to go to the second or third stage for a favorable
decision. We have not had any luck getting the repairs paid by Medicare
unless it went to appeal.

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Sometimes the only thing left to do is bill M/C for another C-Leg

 

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We are now educating our Patients that this may not be a covered service
when they inquire about C legs. We are now having them sign an ABN
explaining that this may not be a covered service

 

 

Thanks to all for your responses. Gary.