New Billing Myths Challenge O&P Industry

Joe McTernan, director of reimbursement services for American Orthotic and Prosthetic Association (AOPA), presented his “Top Ten Billing Myths” at the AOPA National Assembly in Seattle.

McTernan presented some of the most common myths associated with O&P billing, payment and policy. He also explained new myths regarding the implementation of the Provider Enrollment, Chain and Ownership System (PECOS) and inpatient billing practices that have already become a cause for concern in the first quarter of this year.

After reading Medicare’s billing criteria, practitioners could come away more confused than enlightened. Undoubtedly, practitioners want to comply with Medicare’s system requirements, but doing so has become an ever-increasing challenge. O&P practitioners run the risk of compiling unnecessary paperwork and time if they are not fully competent of the billing practices within their profession.

A practitioner’s lack of knowledge regarding O&P billing practices and policy could alter the way he or she treats a patient. One of the most common myths regarding O&P payment is that Medicare will not pay for a diabetic shoe that is worn over a prosthesis. This is not the case, as McTernan pointed out to O&P Business News. Medicare will cover a pair of diabetic shoes for patients who meet the coverage criteria. One of the history criteria, according to McTernan, is a record of amputation on a part or all of the patient’s foot. Another myth that McTernan highlighted in his presentation is that Medicare will not pay for orthopedic shoes. Medicare, in fact, will pay for both custom and off the shelf orthopedic shoes as long as they are an integral part of a brace.

The new year has brought with it new myths and misunderstandings regarding payment and billing requirements. Medicare’s process of implementing the physician PECOS enrollment has sparked a wide-range debate within the O&P industry. The lack of physician education regarding the PECOS requirement is a cause for concern, according to McTernan. Still, McTernan is also concerned about the rumors and myths that continue to plague the PECOS enrollment system.

“The biggest myth I hear regarding PECOS is that physicians have no motivation to enroll because they will still be reimbursed for services they provide directly to patients,” McTernan said. “While the April deadline may not affect them immediately, eventually a physician that is not enrolled in PECOS will lose the ability to bill Medicare for services they provide.”

Another myth the industry should be familiar with is inpatient billing practices.

“Many providers mistakenly believe that rehabilitation hospitals follow the same payment rules as Skilled Nursing Facilities (SNF) when it comes to O&P services and payment responsibility,” McTernan explained.

“There has been long standing exemption that allows O&P providers to bill the Durable Medical Equipment Medicare Administrative Contractor DME MAC directly for most prosthetic services delivered or SNF patients during a Medicare Part A stay.”

According to McTernan, the exemption is specific to SNF billing. Paying for services provided during a Medicare Part A covered rehabilitation hospital stay, remains the responsibility of the rehabilitation hospital that must pay the O&P provider directly for their services.

Finally, McTernan addressed his concerns with decreased Medicare reimbursement. The decrease could potentially impact Medicare claims, as well as the private contract fee schedules that use the Medicare fee schedule as a baseline for calculating reimbursement rates, according to McTernan. Despite the decline of the Consumer Price Index for Urban areas (CPI-U) from June 2008 to June 2009, the O&P fee schedule is only tied to the increase of CPI-U and not the overall change. The 2010 fee schedule remained as it was in 2009 only because of the wording in legislation, McTernan explained.

“Providers will always look for other revenue opportunities when faced with the potential threat to reimbursement rates,” McTernan said. “Unfortunately, this may result in the willingness to be a bit more aggressive when deciding which procedure codes best describe the service that is being provided. AOPA encourages its members to code as they choose but to also be cautious that they are not overly aggressive.”

Aggressive coding may provide short term gain, McTernan reiterated, but the practitioner must always be ready and able to defend the coding decisions that are made as a company.

With health care reform looming, O&P billing will continue to be a challenge for industry practitioners. Understanding of the process and thorough research will help combat and shed light on the myths in O&P billing. — Anthony Calabro

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