Category: DME Coding

Widespread Prepayment Probe for HCPCS Code L4360 (Pneumatic Walking Boot)

Posted on by DME INFO

DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS code:

L4360 (WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)

This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.  Please click here to see entire article: L4360 Probe

Split Coding…..have you adjusted?

Posted on by DME INFO

We recently passed the one year mark of the roll-out of CMS’s changes to HCPCS coding for orthotics.  If you have been tracking this issue, you know that CMS made significant changes to the coding structure by establishing two separate categories of HCPCS orthotic codes:  Off-the-Shelf (OTS) and Custom Fitted (CST).  We thought this would be a good time to review these changes and their implications.

As a reminder, the CMS definitions for OTS and CST orthotics are included below:

OTS Orthotics:  Require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Minimal self-adjustment is an adjustment that the beneficiary, caretaker for the beneficiary, or a supplier of the device can perform and that does not require the services of a certified orthotist or an individual who has specialized training.

Custom Fitted Orthotics:  Require fitting by someone with specialized education, training, and experience in fitting and certification and/or licensing.

You can read more about the changes and what it means to you by clicking here, here and here.

If you are a DJO customer you have probably noticed that DJO now lists two recommended HCPCS codes on applicable product labels:  one code for OTS and another for CST.  Each customer should carefully review the CMS requirements to determine which is the most appropriate code to bill.  Although, for now, the Medicare reimbursement for an OTS code is the same as a CST code, you must still meet the Medicare CST requirements when you bill a CST code. Failure to do so could subject you to Medicare repayments and even fines in the face of a Medicare audit.

For commercial payors, this change has created quite a bit of confusion.  While most commercial payors are recognizing the new codes, there are still some that do not.  We recommend that you check with your commercial payors to see how they are addressing the new coding structure.  Depending on what you find out, you may want to check your payor contracts to determine if updates are indicated. For example, are the OTS codes listed and, if so, is there an associated fee schedule?  And don’t forget to audit your payments to ensure you are getting paid appropriately by both Medicare and private payors.

If you would like more information or have questions about these changes please feel free to reach out to your local DJO representative.

2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule

Posted on by DME INFO

For CY 2015, the update factor of 1.5 percent is applied to the applicable CY 2014 DMEPOS fee schedule
amounts.  For more information and to download the 2015 DMEPOS Fee Schedule please click these links:

CMS Transmittal 3129         2015 Fee Schedule Downloads

Two new off-the-shelf (OTS) knee orthosis codes are effective today October 1, 2014:

Posted on by DME INFO

The following two new off-the-shelf (OTS) knee orthosis codes are effective today October 1, 2014:

K0901    KO Single Upright Pre OTS             Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

K0902    KO Double Upright Pre OTS           Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

These new codes are the OTS versions of L1843 and L1845 respectively, and join the 23 other OTS codes that CMS established as part of the 2014 HCPCS update.  This means that if a product currently coded L843 or L1845 requires only minimal self-adjustment for fitting at the time of the delivery, these new OTS “K” codes are the ones that should be billed to the DME MACs.

The updated fee schedule can be accessed here:  http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS_Quarterly_Update.html

 

Ankle-Foot Orthoses: Walking Boots – Coverage and Coding Issues – Revised

Posted on by DME INFO

HCPCS codes L4360, L4361, L4386 and L4387 describe an ankle-foot orthosis commonly referred to as a walking boot. Walking boots that are used to provide immobilization as treatment for an orthopedic condition or following orthopedic surgery are eligible for coverage under the Brace benefit. When walking boots are used primarily to relieve pressure, especially on the sole of the foot, or are used for patients with foot ulcers, they are noncovered – no benefit category. Medicare covers therapeutic shoes, as described in the Therapeutic Shoes for Persons with Diabetes local coverage determination (LCD), for the prevention and treatment of diabetic foot ulcers.

Suppliers must add a GY modifier to HCPCS code L4360, L4361, L4386 or L4387 if the walking boot is only being used for the treatment or prevention of a foot ulcer. The absence of a GY modifier indicates that the walking boot is being used as part of the treatment for an orthopedic condition or following orthopedic surgery. Claims for HCPCS code L4360, L4361, L4386 or L4387 with a GY modifier will be denied as noncovered.  Please click here for entire announcement.