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Medicare Covering Orthotics?

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

Question:

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:

Here is the info you need to know.  I’ve included citations to support the recommendations.

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.

Josh

Doctor Dies Prior to Dispensing DME

Question:

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 livraison cialis.

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

Question:

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/OrthoticsProsthetics/Documents/ABC-Acc-Standards%209-23-12lores.pdf

http://www.abcop.org/accreditation/FacilityAccreditationFAQ/Pages/Default.aspx

What to Do if a Patient Doesn’t Pick Up Their DME Product?

Question:

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

Question:

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.

Medicare Rules and Coding for Diabetic Patient with Amputation

Question:
For Diabetic patient with amputation, if requirements are met documentation-wise, are patients entitled to ONE pair of shoes, and diabetic orthotics with met/toe fillers per ONE  year? And what codes would be billed?

Answer:
According to NHIC DME MAC A Listserve of June 8, 2012 featured below, Medicare clarified eligibility for L5000, “Partial foot with longitudinal arch, toe filler”.

If foot missing hallux or forefoot, arch support with filler understood to require additional rigidity than foot insert without filler and can be billed as L5000. Medicare allows coverage for a single L5000. If patient has diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts.

If foot missing lesser digit, arch support with filler NOT assumed to require additional rigidity than foot insert without filler and CANOT be billed as L5000. If patient HAS diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts. If patient DOES NOT have diabetes, “partial foot, shoe insert with longitudinal arch, toe filler” can be billed as L5000 only if beneficiary missing hallux or forefoot. It is not appropriate to billing either L5000, A5512 or A5513 is patient does not have diabetes and is missing lesser digit only.

Toe Fillers and Diabetic Shoe Inserts – Coding Clarification

Questions have arisen about the correct coding for shoe inserts used to accommodate missing digits (toes) on feet for beneficiaries with and without diabetes. These items fall under two separate benefit categories and use two distinct Healthcare Common Procedure Coding System (HCPCS) codes, L5000 and A5513.

Beneficiaries without Diabetes
Shoe inserts for beneficiaries with missing toes or partial foot amputations who are not diabetic are considered for coverage under the prosthetic benefit. Code L5000 is described by:

L5000 – PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER

As noted in the descriptor, code L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb/toes. For beneficiaries missing digits, particularly the hallux (great toe), or the forefoot, L5000 inserts are designed to provide standing balance and toe off support for improved gait. The biomechanical control required of L5000 differs from the foot-protective function provided by inserts used as part of diabetes management.

For beneficiaries who are non-diabetic and require accommodation of missing foot digit(s) or forefoot, suppliers must only bill code L5000. Codes A5512 and A5513 describe inserts used with therapeutic shoes provided to persons with diabetes (see below) and must not be billed for non-diabetic beneficiaries.


A separate benefit category allows Medicare coverage of therapeutic shoes and inserts for persons with diabetes. Shoe inserts for persons with diabetes are described by the codes below:

A5512 – FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OF SHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER), PREFABRICATED, EACH

A5513 – FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF PATIENT’S FOOT, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH

For a beneficiary with diabetes missing digit(s) or a forefoot, suppliers have two options for billing inserts:

Option 1: For diabetic beneficiaries who do not require the rigidity and support afforded by code L5000 (e.g., beneficiaries missing digits excluding the hallux), suppliers must bill code A5513 for an insert appropriately custom-fabricated to accommodate the missing digit(s). Codes L5000 or A5512 may not be billed in addition to code A5513.

Option 2: For beneficiaries missing the hallux or a forefoot that require rigidity and support for effective gait, suppliers must bill L5000 for an insert appropriately custom-fabricated to accommodate the missing digit(s) or forefoot as well as providing the foot-protective functions required for a person with diabetes. Codes A5512 or A5513 may not be billed in addition to code L5000.

Suppliers are encouraged to review both the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination and related Policy Article and the Lower Limb Prostheses Local Coverage Determination and related Policy Article for additional information on the coverage, coding and documentation of these items.

The Medicare LCD for therapeutic shoes states that patients with diabetes and ulcerative risk factors may be eligible for a replacement pair of shoes each calendar year.

According to the LCD for lower limb prostheses, Policy Article, Effect January 2011, Replacement of a prosthesis or prosthetic component is covered if the treating physician orders a replacement device or part because of any of the following:

A change in the physiological condition of the patient; or
Irreparable wear of the device or a part of the device; or
The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced.

Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be reimbursed without a physician’s order when it is determined that the prosthesis as originally ordered still fills the patient’s medical needs.

Medicare Billing for Patients with Two Different Shoe Sizes

Question:
A patient needs to have two different sized shoes–one 13, and one 14. I will be charged extra for this and wonder how I’m to pass this charge on. Can I bill the patient?

Answer:
Additional cost incurred by fitting (I assume Medicare) patient with two different size shoes cannot be passed onto patient (assuming that you accept assignment). If you do not accept Medicare assignment you can charge patient whatever you want such that increased cost is borne by patient. Less significant differences in foot size (especially in width) can sometime be accommodated with the same size shoe by removing spacers from the larger foot and adding spacers to the smaller foot. domain search availability Alternative, if size is significant enough is to cast patient for custom molded shoes.

Josh White, DPM, CPed
joshwhite@safestep.net

Expiration Date of Form Signed by the Primary Care Physician for a Pair of Diabetic Shoes?

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Is there a time period for the validity of the form signed by the PCP for a pair of diabetic shoes?  How far ahead of the dispensing can the PCP sign the form?

Answer:

Medicare states:
  • 3 months: Time allowed from when certifying physician signs certifying statement to when shoes must be fit.
  • 6 months:  Time prior to fitting shoes that patient needs to have been seen by the physician managing their diabetes using which diabetes care is reviewed.
According to Local Coverage Article for Therapeutic Shoes for Persons with Diabetes – Policy Article- Effective July 2010 (A37065):
For claims with dates of service on or after 1/1/2011, the certifying physician must:

  • Have an in-person visit with the patient during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
  • Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.
Josh White, DPM, CPed

What is the Best Way to Measure Shoe Size for Patients Wearing an AFO?

Arizona AFOMost any AFO makes shoe fitting more challenging; the bulkier the device, the harder to fit shoes. The most important concept is the importance of fitting from the inside out. That is, the shoes must accommodate the foot, insert and AFO. Shoe design is as significant as size for effective fitting.

Features of shoes best to fit over an AFO:

  • Incorporate rocker sole if propulsive gait and AFO limits ankle and STJ sagittal joint motion
  • Full contact sole that does not taper in midsection.
  • Firm heel counter that do not twist easily.
  • Removable footbed
  • Removable spacers

Shoe styles determined to fit best over AFOs are indicated in the SafeStep shoe catalog and on the website with an AFO icon.

When sized properly:

  • There should be 1/2″ space between the end of the longest toe and the end of the shoe.
  • Ensure that the shoes are wide enough such that the foot does not bulge the lateral side.

Fitting will be best accomplished in the office with the use of a display stand or with pairs of shoes to try on. When the fitting is challenging or if one foot is significantly different in size or shape than the other, its best to refer patient to store where shoes can be tried on over AFO.

Fit may be best accomplished by removing spacers from shoe with AFO and adding to shoe without.

If foot with an AFO much larger and different in shape from contralateral side, best option is custom molded shoes made over AFO. Entails first molding for AFO and then for shoes afterwards. Custom shoes are only covered by Medicare for patients with diabetes or if AFO attaches to shoe. Alternatively, Arizona AFO makes a custom shoe with built in brace called the Closed Toe Walker.