Wiki DME documentation guidelines...first denial!

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twalls

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Hello All! Can someone shed some light on documentation guidelines for orthotics, shoes and boots? I am familiar with CMS guidelines/requirements for diabetic shoes. But out of the blue I have received a denial for a pair of orthotics for a 8yo whom did not require a prior auth, (called and confirmed) and the denial states there isn't sufficient detail of custom fabrication to support the charges, L3000. In addition no documentation of a signature log/illegible signature per CMS requirements. First denial in 3 years! What am I missing?!
Thank you!
Tammy
 
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Great question! Custom orthotics are not covered by CMS except when attached to a brace. If you are billing CMS to get a denial so that you can bill the secondary, you would add the GY modifier. For other payers, if they follow the CMS rules, then custom orthotics are not covered. If you can provide me with more specifics about payer etc I can give you additional help.
 
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podcoder70 said:
Great question! Custom orthotics are not covered by CMS except when attached to a brace. If you are billing CMS to get a denial so that you can bill the secondary, you would add the GY modifier. For other payers, if they follow the CMS rules, then custom orthotics are not covered. If you can provide me with more specifics about payer etc I can give you additional help.
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The payor is a managed Medicaid called Molina Healthcare for a 8yo child who we called and asked if it was a covered benefit and were told, no auth was necessary. They were molded, made and billed with M76.822, M76.821- L3000-RT and LT and denied for insufficient/not support for the billed charges, to include insufficient details to support the code billed. And then for good measure they threw in the the illegible signature per CMS guidelines/lack of signature log.
 
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