Orthopedic Coding Alert

Editors Note: Part one of this three-part series reviews strategies to simplify billing for supplies and orthotics. Over the next two months, part two will offer a closer look at billing selected supplies and orthotics for the extremities, and part three will consider the same for those supplies and orthotics used in treating and ameliorating conditions of the head, neck and torso.

Nugget: Confusion about how to bill has caused some orthopedic practices to lose the cost of supplies sent home with patients.

How do orthopedic practices view billing for supplies and orthotics? In most cases, they say they hate it, says Kathi Erickson, president of Innovative Health Services in Twinsburg, Ohio. The billing process will be improved if you know where and when to bill, who can bill and what to bill.

The Health Care Financing Administration Common Procedure Coding System (HCPCS) applies to medical and surgical supplies (A series), orthotics and prosthetics (L series) and durable medical equipment (E series). Carrier discretion and special coverage instructions for HCPCS codes are wide-ranging and highly variable.

Billing for supplies and orthotics has three problem areas.

1. Where and when to bill: Medicare requires claims for certain items to be submitted to the Durable Medical Equipment Regional Carrier (DMERC). Some claims, i.e, surgical dressings, such as A6206 (contact layer, 16 sq. in. or less, each dressing), are included as part of the professional service and cannot be submitted separately.

Yet if the same dressings are given to the patient to take home and use in home care, they can be billed (to the DMERC). Therein lies another layer of complexity for orthopedic practicesseparately inventorying supplies sent home with patients and used in the office.

2. Who can bill: Some items cannot be billed at all by an orthopedist. For example, an orthopedist may prescribe diabetic shoes and do the fitting and modifications, but a podiatrist, pedorthist, orthotist or prosthetist must do the fitting and furnishing.

Moreover, a separate Medicare category (of Medicare Part B) covers therapeutic shoes for patients with diabetes and specifies the calendar-year limits for shoes (custom molded and depth) and inserts. The physician in charge of diagnosing and documenting the diabetes must certify that the patient has diabetes. That physician or another qualified physician, i.e., an orthopedist, can write the prescription for the shoes. If the patient later needs a brace in addition to shoes, the brace is coded the way a corresponding brace for a person with any condition would be.

3. What to bill: There can be advantages to billing certain durable medical equipment as an orthotic device instead of durable medical equipment. And suppliers of wheelchairs to patients in skilled nursing facilities have challenged the Social Security Administration in its own hearing rooms and in the United Sates Circuit Court of Appeals regarding the classification of wheelchairs. Suppliers argue the wheelchair can be viewed as an orthotic device, one that is meant to help retain musculoskeletal function.

A wheelchair has been characterized in court proceedings (No. 97-2047, United States Court of Appeals for the First Circuit) as [a medical device] intended for persons with severe musculoskeletal failure, [a] set of connected braces attached to a wheeled base. Such claims can be expected to grow along with the population in skilled nursing facilities. (See box for more information on billing for wheelchairs.)

Note: In the prevailing lexicon used for HCPCS categories, orthotics have therapeutic value, prosthetics replace structures and perhaps some function, and durable medical equipment is something that may be palliative, but which is interchangeable among some segment of the population.

Not Billing At All, and Getting Help

Some orthopedic practices simply lose the cost of supplies sent home with patients, charges that could legitimately be billed. Others are finding help from suppliers.

We bill for physicians, explains Erickson. We buy inventory, put it in [the office or facility] and track it. Physicians dont have any of the headaches of billing for DME.

Ericksons company also offers a mobile cast molding service for prosthetics. Specialists go to a patients home. Physicians really like it, she says.

Another company that is taking some of the billing problems out of the hands of physicians is Hanger Orthopedic Group in Bethesda, Md. We are the largest provider of orthotics and prosthetics in the United States, explains Joe McTernan, director of regulatory affairs for Hanger. Ninety-nine percent of our business is based on referrals from physicians.

Hanger is not paid for professional services. Patients arrive with a prescription for an orthotic or prosthetic, and they are fitted and followed until the fit is correct. Certified orthotists and certified prosthetists do the custom work. All follow-upuntil the device is complete and functionalfalls under the global for the application. McTernan points out that the way the HCPCS codes are written allows for some separate coding and gave the example of L1970 (ankle-foot orthosis, plastic molded to patient model, with ankle joint).

The L1970 is the base code and is the lower payment. If special additions are needed, such as L2180 (addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints) they can also be coded. Hanger not only bills Medicare but has contracts with most major payers nationwide.

Note: If your practice has an anecdote about billing for supplies and orthotics that it would like to share for parts two or three of this series, we would like to hear from you.

Correct Billing for Wheelchairs What is the advantage to gaining universal (legal) recognition for a wheelchair as an orthotic device? It would remove the wheelchair from the category of durable medical equipment that Medicare says is sometimes a convenience and sometimes a medical necessity. It would also acknowledge that in some settings (i.e., skilled nursing facilities) maintenancethrough supportof the musculoskeletal system is as important as are interventions to correct problems with specific diagnoses. Successful reimbursement for any item in the DME category to which the wheelchair belongs begins with a Certificate of Medical Necessity (CMN). The treating physician must complete and sign the CMN. Unfortunately, there is no comprehensive CMN. In the case of a wheelchair, DMERC form 02.02A applies to motorized wheelchairs, and DMERC form 02.02B applies to manual wheelchairs. Moreover, the CMN rules are quite rigid. For example, a motorized wheelchair (e.g., K0012, lightweight portable motorized/power wheelchair, K0013, custom motorized/power wheelchair base) will sometimes meet criteria for DMERC reimbursement and sometimes not. A 65-year-old patient with casts on both arms and legs who is lucid enough to operate the chair would be eligible for reimbursement (up to 80 percent of eligible cost). But a patient of the same age who suffers from dementia and cannot operate the motorized chair would fail one CMN criterion (being able to use the equipment appropriately), and the patient would not be eligible. If the physician had direct contact (one-to-one) training the patient to use a motorized chair that met CMN criteria, he or she could bill for CPT 97542 (wheelchair management/propulsion training, each 15 minutes). Because the training must be geared to improving function, a demented individual would be excluded as a recipient of the service.