Navigating the Rough Waters of Medicare Coding and Billing

Certified pedorthists admittedly struggle, along with other practitioners, to decode the language of Medicare billing and coding paperwork. The Pedorthic Footwear Association (PFA), recognizing this hardship, is working to establish a strategic partnership with a nationwide billing company to offer their services to PFA members, according to Brian Lagana, PFA executive director. Billing companies offer a less stressful route for even the smallest pedorthic practice, he explained.

Christine Duprey and Carrie Romandine, co-founders of CARIS Innovation, a medical consulting company with clients nationwide, will present a program regarding the confusion surrounding Medicare billing and coding at the 50th annual PFA symposium Nov. 6-9 in Nashville, Tenn.

In 2003, Duprey and Romandine started CARIS Innovation in Abrams, Wis., as a firm specializing “in helping providers with their revenue cycle management functions,” Duprey said adding that many CARIS clients are board-certified pedorthists. More than a few of them admit that trying to figure out Medicare billing and coding can be a close encounter of the worst kind.

Getting organized

“Pedorthists around the nation are challenged with the constant changes and requirements for government billing,” Duprey said.

Erick Janisse, CO, CPed, who operates the St. Louis branch of National Pedorthic Services (NPS) agrees.

“If you code something incorrectly the best case scenario is you don’t get paid,” he said. “The worst case scenario is you are prosecuted for Medicare fraud.”

Navigating the Rough Waters of Medicare Coding and Billing
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Dennis Janisse, CPed, founder of NPS, hired CARIS to help his company ensure that its billing and coding procedures were correct.

“We were getting all kinds of stuff denied for myriad reasons and they helped us get organized using their experience on the ‘other side’ of insurance billing and by re-analyzing the terms of our contracts,” Erick explained. “They were able to figure out the idiosyncrasies of each health plan, and now we know who requires what. It has dramatically reduced our number of denials.”

Duprey hopes she and Romandine can help shrink the number of denials and prevent unnecessary payment delays for symposium-goers, too. She said that while each of the four Medicare regions “generally…follows similar guidelines for the adjudication of claims,” those guidelines do not always provide enough guidance for certified pedorthists and other practitioners.

Potential pitfalls

Duprey outlined four potential pitfalls for certified pedorthists trying to collect money for the services they provide Medicare beneficiaries.

First, Duprey cited incomplete Advanced Beneficiary Notice (ABN) forms.

“As a provider that services the Medicare population, it is important to understand the function and purpose of the ABN form,” she said adding that sometimes a service Medicare usually covers may not be covered because of special circumstances. These circumstances include:

  • The service is not medically necessary;
  • The patient does not meet the conditions for coverage;
  • Appropriate documentation is not on file; or,
  • The patient’s condition is not approved by Medicare for a particular service.

“The provider…must have an ABN form completed and signed by the patient in order to collect payment for the services from the patient,” she said.

Second, certified pedorthists need to be careful with modifiers.

“Medicare has specific requirements for the use of modifiers when billing,” Duprey explained. “The most typical modifiers when billing for pedorthic services are “left” (LT), “right” (RT), “not covered” (GZ) and “all documentation is on file/patient meets all requirements and this is an eligible charge” (KX). The use of modifiers changes with the type of service you are billing.”

For example, Duprey said, when billing for knee-ankle-foot orthoses (KAFO), modifiers must indicate to which foot, ankle or knee the orthoses will be fitted.

Each of the four Medicare regions follow similar guidelines for the adjudication of claims but those guidelines do not always provide enough guidance for certified pedorthists and other practitioners.

“If you are billing for bilateral L1960 AFO, posterior solid ankle, plastic, custom fabricated orthoses, you would need to indicate L1960 LTRT 2.0 units on one claim line,” she said. “If you are billing for a rocker bottom modification and [it] is being made to a shoe that is attached to a brace, you would indicate the appropriate LT or RT modifier (both if done bilaterally) as well as the KX modifier to indicate all documentation and conditions have been met. Remember, billing for a shoe attached to a brace, the shoe must be an integral part of the brace, meaning it must physically be attached to the brace to be covered. In this example, you would bill L3400 LTKX 1.0 if the patient met all conditions. If not, you would bill L3400 LTGZ 1.0 and indicate this item is not covered for this patient. In this example, you need to have an ABN form on file to collect from the patient.”

When billing for therapeutic footwear, modifiers are used slightly differently for bilateral services, Duprey said.

“If the patient has met all of the criteria to receive a therapeutic shoe, you would bill A5500 KX 2.0 when receiving a pair of shoes. If the patient were only receiving one shoe, you would then add a modifier A5500 LTKX 1.0 to the service line,” she said.

Duprey continued explaining that it is crucial for practitioners to know when and how to bill modifiers for all of the services they perform.

“This will help you to avoid rejections and denials for lack of information and inappropriate use of a modifier,” she said.

Third, providers who have not filed with the National Plan and Provider Enumeration System (NPPES) database– or have failed to update their information since their initial application–could experience long delays and collection difficulties. Duprey said most providers applied for National Provider Identifier Standard (NPI) numbers when the rule was introduced, but they have not updated the database since.

“The NPPES…has been updated and requires practitioners to update the information for the purpose of creating a crosswalk to the government and soon, commercial payers. If this crosswalk cannot be created from the NPPES database, there is a chance that the provider will experience a delay in the Medicare processing,” Duprey said. “In most cases, Medicare is not rejecting or sending the claim back for additional or updated information. They are deleting the claims from the system. Upon a status check to Medicare you may notice there is no claim on file due to this issue. It is important to correct this problem immediately to avoid further delays in the payment process.”

She added, “DME providers fall under an exception to the enumeration strategy of NPI in that all DME provider locations where items are dispensed must have their own NPI number. Government agencies have not been able to create an up to date cross-walk of information for the providers who have not updated their data in the NPPES database. Medicare has been making significant changes to their billing requirements in accordance with NPI for the implementation date of May 23, 2008, and the crosswalk is essential for them to adjudicate claims correctly.”

Duprey also cautioned that “lack of compliance for billing will lead to unpaid claims, lengthy delays and in some cases a cancellation of your Medicare numbers. Avoid further delays, update the database, verify your information is correct with the National Supplier Clearinghouse, review your Medicare applications to ensure all information within these resources is a match and follow up on all claims in an outstanding status for more than 30 days.”

“Medicare is not rejecting or sending the claim back for additional or updated information. They are deleting claims from the system.” Christine Duprey

Fourth, Duprey said certified pedorthists need to remember that Medicare only provides shoes for diabetic patients under Medicare’s Therapeutic Shoes for Diabetics Benefit – TSD.

If a diabetic patient meets the specific coverage conditions, they may be eligible for one pair of extra depth shoes and three pairs of inserts per year or one pair of custom molded shoes and two pairs of inserts, Duprey explained. If a bilateral pair of extra depth shoes is purchased, the LT RT modifiers are not required. This claim can be billed with the KX modifier and a unit of 2.0 on the claim.

“The pitfall to billing under the Therapeutic Shoe Bill is interpreting and billing correctly for the number of inserts allowed. This bill may allow a patient to receive three pairs of inserts (not including the ones that come with the shoe) or one pair of inserts and four modifications to the pair of extra depth shoes. Each modification that is done to the pair of extra depth shoes replaces a unit of the inserts,” she said.

Duprey added, “For example, a patient receives one pair of extra depth shoes, two pairs of inserts and two modifications (rocker bottoms on both shoes). The claim would be billed as such: A5500 KX 2.0, A5513 KX 4.0, A5503 KX 2.0. This would fulfill the number of shoes and inserts this individual was allowed for one calendar year. Providers often replace the billing of the A5503 rocker bottom for an A5513 insert, the claim must represent what was billed. Modifications that replace an insert only means the patient is allowed 6.0 units. The patient can have any combination of inserts and modification units up to a combined total of 6.0. All services must be billed as they are provided; you may not bill an A5513 when you performed an A5503.”

Questions to consider

“Filing claims electronically can provide you with a faster turn around time for your accounts receivable. Medicare can adjudicate the claims and send an electronic fund transfer.” Christine Duprey

While she and Romandine field many questions from providers, Duprey said they frequently get the most basic query of all: “Whether or not they should become a participating provider for Medicare and service Medicare beneficiaries.”

To address this inquiry, she posed five questions practitioners might ponder in deciding whether to go with Medicare or not.

  • Do you know the average age of your patient population?

    “Determining the average age…will help you to relate the percentage of Medicare beneficiaries to the revenue you can anticipate when accepting the Medicare allowable amount as payment in full,” Duprey said.

  • How do your costs compare to Medicare’s allowed amounts?

    “The fee schedule for Medicare allowable amounts is available to all providers. If your costs are higher than the Medicare allowable amounts, this would be an indicator that these services will be provided to the Medicare beneficiaries at a loss,” she said. “Consider not only your costs to actually purchasing the supplies and providing the service but also to the necessary profit margin to manage your business.”

  • Do your referring physicians accept Medicare and if so, would it affect your referrals if you didn’t service Medicare beneficiaries?

    “Since the majority of the patients seen by pedorthists are sent by referral, it is important to know what the dynamics are for the population your referral base is serving,” she said.

  • Could you help your business if you accepted Medicare beneficiaries?

    “When looking at increasing your volume of Medicare or commercial carrier beneficiaries, evaluate the costs versus revenue to determine whether this is the population you want to increase. Have you researched the administrative functions and costs associated with billing Medicare? In addition to understanding the costs associated to the products and services you are offering, it is also important to understand the billing requirements, beneficiary responsibility, provider discounts, timely filing requirements and appeal rights associated with accepting assignment or what benefits are lost when not accepting assignment,” she said.

  • Do you file your claims electronically?

    “Filing claims to Medicare is required unless you meet the definition of a small provider and have filed for an exception to file your claims via paper and received approval to do so. Filing claims electronically can provide you with a faster turn around time for your accounts receivable. Medicare can adjudicate the claims and send an electronic fund transfer to your bank account typically within 5-7 days if the claims are submitted as a ‘clean claim,’ meaning all of the information is present and correct for processing.”

Duprey concluded that whether to service Medicare beneficiaries is a big question for certified pedorthists and other providers.

“The process of determining whether or not to service Medicare beneficiaries is an individual analysis that the office must conduct to ensure taking on Medicare beneficiaries doesn’t adversely impact the overhead and profit margin to the clinic,” she said. “At the end of your analysis, you should be able to determine whether or not to service Medicare beneficiaries as a participating or non-participating provider or if you will choose not to service the Medicare population based on costs and reimbursement.”

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Berry Craig is a correspondent for O&P Business News.

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