Archive for Q & A
Medicare Covering Orthotics?
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Question:
I heard through the grapevine that Medicare has started to cover orthotics.
Is this true or rumor?
If they are covering does anyone know what diagnosis, and whether the coverage is for L3020?
Answer:
Foot orthotics (L3xxxx) are not covered, and likely will never be for the vast majority of Medicare patients.
The only circumstance where foot orthotics (L3xxxx) are covered under Medicare is when a patient has a leg brace attached to the shoe and that shoe (billed and covered by Medicare) is an integral part of that brace. Only the supplier who provides the shoe and the brace can provide and bill for the foot orthotic.
Not meeting that requirement, yet still billing L3xxxx with a “KX” modifier indicating that you DID meet the very strict requirements may be construed as potentially fraudulent billing.
Taking Over A Practice Which Has An Active DME Number
Posted by: | CommentsQuestion:
My partner’s wife is taking over a practice which has an active DME number with the contact person as the original owner. How difficult is it for her to change the contact person and supplier to herself? Will she be required to submit an entirely new DME application even though the tax ID of the practice will remain the same?
Answer:
A CMS-855S needs to be completed to submit Change of Information.
“Change of Information Other Than Adding a New Location
If you are adding, deleting, or changing information under your current Medicare supplier billing number. Any change to your existing enrollment data must be reported within 30 days of the effective date of the change.”
For Change of Ownership and/or Managing Control there is a section that should be selected.
It directs the supplier as to what sections in the application must be completed:
“Ownership and/or Managing Control Information (Individuals)
1C, 2A1, 3, 6, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and 6 for the signer if that authorized or delegated official has not been established for this DMEPOS supplier.”
There are a couple things that they should know in completing the form:
Section 2.A.1 – Supplier Identification
This information should identically match the current information that is on file with the National Supplier Clearinghouse.
If it is an Organization, chances are that the same DMEPOS PTAN may be kept.
If the current supplier is a Sole Proprietor, using an EIN with a DBA, chances are that the new supplier will get a new number.
Section 3 – Final Adverse Legal Actions/Convictions
This section MUST be answered “Yes” or “No”.
If the answer is Yes, then “Yes” should be checked and details listed.
If the answer is “No” then they should check off “No” and continue on to the next section.
Section 6 – Ownership Interest and/or Managing Control Information (Individuals)
This page is used to identify the new owner as being added and should be completed in its’ entirety.
New individual information should be added.
Exiting individual should be “Deleted”
PLEASE NOTE: This page needs to be submitted for each individual. Make copies of this page as needed.
Section 13 – Contact Person
It is always suggested to have someone, other than the supplier, as an additional contact person in case there are questions.
Section 15 – Certification Statement
The application must be signed. Copies or stamps are not acceptable.
Section 17 – Supporting Documents
Copy of your bill of sale if you purchased an existing DMEPOS supplier with an active Medicare supplier billing number.
Please let me know if I can be of further assistance.
Doctor Dies Prior to Dispensing DME
Posted by: | CommentsQuestion:
If my doctor passes away before the patient picks up their DME item, would these claims be billed differently than a normal DME claim? My concern is that the date of service, while coinciding with the date of pick-up, will occur after the date of death of the doctor. Any suggestions?
Answer:
Ancillary personnel cannot dispense DME, just as they cannot bill for surgery that was not performed by the physician who employs them.
If the practice was taken over even temporarily by another physician, (assuming they have a DME number), then that physician could bill for the device as the supplier.
Obtaining Facility Accreditation to Get Paid by Private Insurers for Dispensing DME
Posted by: | CommentsQuestion:
Josh,
My office is currently having problems getting paid by some insurance plans as they question our ability to dispense products. Like you, I graduated from the CCPM School and I believe I have great training in orthotics, AFO, and DME equipment that makes me more qualified than most DME suppliers. The bottom line that most private insurance companies are saying I need to be certified by ABC or another group. Has your office done this and if so what certification organization did you use? Did you get certified as an individual or group? Do you have any recommendations or suggestions that would help?
Answer:
Sorry to hear about your troubles getting qualified to get paid by private insurers for DME.
DSPMs are lucky in that we are exempt from obtaining facility accreditation to get paid for dispensing DME. Non-physician suppliers like orthotists, prosthetists, CPeds, pharmacists are not. They get Facility Accreditation form either BOC or ABC.
DPMs can get facility accreditation and in fact Jonathan had his facility pass the requirements.
Private insurers can make their own rules and so I believe it is legitimate what they are asking of you to be a qualified provider.
Getting facility accreditation for your practice is not that onerous and might be very much worth it for the benefit of providing products to these patients. It might even open the door to other non-accredited providers referring their patients to you. The few DPMs I know who have gone through it have said that the process improved their organization overall.
Below are links and info for the accrediting organizations.
Here is a copy of a presentation I prepared several years ago when it was looking like a Medicare requirement for DPMs:
Basics of Facility Accrediation
As always, SafeStep is here to help.
Best regards,
Josh
Accreditation Links:
http://www.bocusa.org/becoming-accredited
http://www.bocusa.org/files/Facility_Accreditation_Standards.pdf
http://www.abcop.org/accreditation/FacilityAccreditationFAQ/Pages/Default.aspx
What to Do if a Patient Doesn’t Pick Up Their DME Product?
Posted by: | CommentsQuestion:
If a DME product was fabricated and paid by the carrier, but the patient does not come to pick it up despite proper scheduling, what is the responsibility of the podiatrist?
Answer:
Medicare Benefit Policy Manual
Chapter 15 – Covered Medical and Other Health Services
Publication 100-02, Chapter 15, Section 20.3
20.3 – Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3
A. Date of Incurred Expense
If a custom-made item was ordered but not furnished to a beneficiary because the individual died or because the order was canceled by the beneficiary or because the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made based on the supplier’s expenses. (See subsection B for determination of the allowed amount.) In such cases, the expense is considered incurred on the date the beneficiary died or the date the supplier learned of the cancellation or that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed and the item was no longer reasonable and necessary or appropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, for any other reason, canceled the order, payment can be made to the supplier only.
B. Determination of Allowed Amount
The allowed amount is based on the services furnished and materials used, up to the date the supplier learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The Durable Medical Equipment Regional Carrier (DMERC), carrier or intermediary, as appropriate, determines the services performed and the allowable amount appropriate in the particular situation. It takes into account any salvage value of the device to the supplier.
Where a supplier breaches an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item. Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case.
There are slight variations in the procedure of each DME carrier and the provider has to call and find out and follow those, but for the most part they are similar to what is outlined below.
According to National Government Services, one of four Medicare DME MACs:
1) Submit a claim with the FULL billing amount you usually bill.
a. Date of Service should be Date of Refusal or Date of Death
2) Include in the narrative section a brief explanation of the situation. Mention that the item ‘has no salvage value and is a complete loss’.
3) After receipt of claim, they may ask for more information such as a receipt of the purchase of the item, explanation of your other related costs such as staff time, your own time, etc. It is their discretion depending on many factors such as How often you have claims such as this, the total amount involved, and other DME history of patient and provider.
4) Based on all this, the carrier will pay whatever they feel is appropriate, even up to the full amount billed or….nothing at all!
5) This decision can be appealed up to the various levels following usual procedures
DME Supplier Hours Open Requirements
Posted by: | CommentsQuestion:
DME supplier standards #30 states
“DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.”
We have a satellite office that we see patients and as it happens also dispense DME items to them. We, however, do not meet the 30 hours requirement. There is a family practice doctor who is at the location the rest of the time so the office is not technically closed.
Will this create problems for us in a DME audit?
Any solutions?
Our main office meets the 30 hours and we dispense DME items from it. Someone is available to answer our phones also most of the week.
Answer:
Physicians offices who supply DME to their own patients are exempt from the 30 hour requirement. The issue of the family physician sharing the same office space is also not an issue as physicians who supply DME only to their own patients can share office space. This is irrespective of whether both physicians have (or only one has)supplier number(s).
Physicians who own a commercial DME company, however, are not exempt from the 30 hour rule, nor may they share space together. Examples would be a podiatrist who owns a shoe store or a pulmonologist who owns an oxygen supply company. Both would be precluded from sharing the same physical space and both would need to be open to the public for a minimum of 30 hours.
Bottom line: your scenario exempts you from the both the 30 hour rule and the sharing space rule.
