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Charge vs. Allowed vs. Reimbursed

Posted by Linda Collins | June 27, 2017

How do I know what dollar amount is being paid?

The explanation of benefits (EOB) which comes with payment from the insurance company can offer information about what is and is not paid. The terminology used can also be confusing.

Charge – this is the dollar amount put in box 24F on the HCFA claim form. This amount is your retail price.

Allowed – this is the dollar amount in the payer's fee schedule for this particular code. This is the dollar amount the payer will pay for this covered service.

Contractual Write-off – this is the difference between charges and allowed in the payers' fee schedule. You agree to accept the fee schedule allowed amount when you sign the contract with a payer. The difference between what you charge and allowed amount is a write-off. You are not able to bill the patient for the difference.

Patient Responsibility – the portion of the allowed amount the patient must pay. This may be coinsurance, copayment, or a deductible amount.

Here is an example of a payment to assist in understanding what payment is from the insurer and what payment is from the patient.

Charge – $1200.00

Allowed – $840.00

Contractual Write-off – $360

Patient Responsibility – $168.00

Paid from the Insurance Company – $672

You will receive $672 from the insurance company and collect $168 from the patient for a total allowed amount of $840.00

Each EOB is different and may use various terminology. Take the time to review your EOB and understand where your money is coming from.

Previous posts

June 22, 2017

Region D Posts New Spinal and AFO/KAFO Review Data

Noridian has released the latest claim review data for both spinal orthoses and AFOs/KAFOs. Read this post to get the details.​

June 20, 2017

Which Modifiers are Required?

​Question of the Week

June 16, 2017

Reminder: Payer Trends Affecting Prosthetic Claims Webinar

​Tuesday, June 20th  12pm-1pm

June 14, 2017

New Region D Prepayment Claim Review Results

Noridian has published the results of its latest prepayment claim review for knee orthoses. Read this post to learn more.

June 08, 2017

What is a Medically Unlikely Edit?

​Question of the Week

June 05, 2017

New Version of ABN Form

​The Advance Beneficiary Notice of Noncoverage (ABN) form notifies patients that Medicare may deny the service or item provided. Effective June 21, 2017 there is a new version of the ABN form all suppliers must use.

June 01, 2017

Webinar: Payer Trends Affecting Prosthetic Claims

Össur R&R Webinar: Payer Trends Affecting Prosthetic Claims

​Tuesday, June 20th, 2017 12pm-1pm EST

May 31, 2017

A New Resource From AOPA

The American Orthotic and Prosthetic Association has launched the AOPA Co-OP​. What is it and how does it work? In this post, we introduce you to this important and excellent new resource.

May 25, 2017

How Often Can I Provide a New Prosthetic Socket?

​Question of the Week

May 23, 2017

Region D Knee Orthosis and Ankle-Foot Orthosis Prepayment Claim Review Results

​Noridian has released new results of its prepayment claim reviews for both knee orthoses and ankle-foot orthoses. Learn what you need to know in this post.

May 22, 2017

Same or Similar Orthotics

​A supplier may receive a denial when the claims history indicates a “same or similar” device previously billed for the same patient within the reasonable useful lifetime of the brace.

May 18, 2017

Region D Spinal Orthoses Claim Review Results

Noridian has announced the latest results of its prepayment claim review for L0631 and L0637 in Region D. Read this post to get the key stats and identified issues.​

May 17, 2017

Providing Back Braces to a Patient in a Hospital

​When a patient is in a hospital or skilled nursing facility (SNF), most services are included in the payment to the facility. This includes all orthotic devices used by the patient during the stay.

May 15, 2017

A Two-Fer: L5845 Audit Issue Update and HCPCS Coding Workgroup Preliminary Decisions Published

Medicare's HCPCS Coding Workgroup has published its preliminary decisions regarding new code applications submitted for 2018. Read this post to learn which products got codes and which did not.​

May 12, 2017

How do I use an ABN when the Product May Not be Covered?

​Question of the Week

May 09, 2017

Medically Necessary Criteria for Spinal Braces

​In order for an item to be considered for coverage by Medicare, it must be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…" The Local Coverage Determination (LCDs) give detailed information about medical necessity requirements for Spinal Orthoses.

May 04, 2017

Prepayment Review of HCPCS L5856 Announced by Region C

​DME MAC, Region C, announced they will begin a wide spread prepayment review of all claims with HCPCS L5856. The review will begin in June.

May 03, 2017

Coding for Spinal Braces

​Spinal Orthoses have specific HCPCS codes for each product and for the type of product, off the shelf, custom-fit, or custom.  One additional requirement is that spinal orthoses must receive a coding verification review from PDAC in order to be considered a covered item.

May 01, 2017

L5845 Audit Issue Removed from Performant's Website

​An update on an audit issue added, revised, and then removed from Performant's website.

April 28, 2017

Reasonable Useful Lifetime of a Custom Brace

​Medicare defines a Reasonable Useful Lifetime (RUL) for many items. RUL is the expected minimum lifespan for the item.

April 26, 2017

Medicare Does Not Cover All Devices

If a particular device is excluded from Medicare coverage, it is acceptable to sell it as a cash item and accept payment from the beneficiary at time of delivery.

April 21, 2017

MAC Region A Announces New Prepayment Targeted Review

The DME MAC for Region A has announced it will be commencing a Service Specific Prepayment Targeted Review for certain spinal orthosis codes. What do you need to know? Read this update to find out.​

April 19, 2017

Ankle Braces: What is and is not covered

​In order for an item to be considered for coverage by Medicare, it must be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…" The Local Coverage Decisions (LCDs) give detailed information about medical necessity requirements for various types of braces.

April 13, 2017

Össur R&R Webinar: All About Billing Braces

​Last chance to register!

April 05, 2017

What Does a PDAC Letter Really Mean?

​We are continually asked if a product has a "PDAC letter." What does this really mean and which products actually require coding verification letters? Let's start with a review of PDAC.

March 30, 2017

All About Billing Braces - Webinar

​Ankle, knee and spinal braces all have coding and medical necessity criteria. Join us in this webinar to learn more about the unique criteria for each brace type, the documentation, coding and billing will be discussed.

March 24, 2017

Ankle and Knee Brace Audits

​Noridian, Jurisdiction D, DME MAC, is continuing audits on specific AFO and KO HCPCS codes. They recently published results of the fourth quarter 2016 audits.

March 21, 2017

Össur Academy Clinical Webinar - Eligible for 1.5 CEUs

​Attendees of this webinar will learn the different designs and application of the Medi line of mechanical knees. Justin Pratt, CP and director of Össur Academy, will present the features, functions, benefits, coding and proper K levels for each mechanical knee.

March 16, 2017

Billing Repairs

​When an orthosis or prosthesis has to be repaired, and is no longer under warranty, there are specific labor and parts codes you can use.

March 14, 2017

National RAC Kicking Off Audit Activity

​Medicare just announced that its new national RAC auditor for DMEPOS claims - Performant Recovery - will be starting its audit activity. How does this affect O&P suppliers? What do you need to know? Read this post to find out.

March 06, 2017

Prosthetic Service in a Skilled Nursing Facility

​Medicare provides skilled nursing facility (SNF) benefits, when medically necessary, under the Part A benefit. The payment to the SNF is all inclusive under the Prospective Payment System. There are exclusions to the SNF payment, which are to be billed separately to Medicare.

February 10, 2017

Össur R&R Webinar | 2017 So Far: Transition and the Effects on O&P

A new President; Republicans have taken control of both the House and Senate; the fight over health care reform - lots is happening, but how does this affect health care professionals who provide prosthetic and orthotic care for their patients? Listen to Össur R&R's first podcast of the year to learn what's happening, what might happen later this year, and how you can prepare for it.

February 07, 2017

On Second Thought ...

CMS withdraws a previous announcement on competitive bidding.​

February 06, 2017

Recovery Auditor Contractor (RAC) Training

Recently, Performant Recovery announced they will be offering a series of educational webinars to introduce the Performant RAC team. The webinars are free of charge and open to all DMEPPOS suppliers. 

February 01, 2017

Competitive Bidding Update: Round 2019

Medicare has announced a new round of competitive bidding. What products are included? When will it start? How does it affect you? Read this post to learn more.​

January 30, 2017

The C2C Telephone Discussion: What is it and Should You Do It?

​What is the C2C telephone discussion? Is i​t something you should consider doing? Learn important info about this program from guest author Stephanie Morgan Greene of The Audit Team.

January 27, 2017

Össur R&R Webinar on February 17, 2017

​A new President; Republicans have taken control of both the House and Senate; the fight over health care reform - lots is happening, but how does this affect health care professionals who provide prosthetic and orthotic care for their patients? Listen to R&R's first podcast of the year to learn what's happening, what might happen later this year, and how you can prepare for it.

January 20, 2017

Medicare Proposed Rule Re. "Qualified Practitioners"

Medicare recently published a proposed rule addressing who is qualified to provide custom-fabricated orthotics and prosthetics. How does it affect you? What do you need to know? Read this post to learn more.

 

January 17, 2017

Appeals and Complaints: Private Insurance Companies

You see a patient with private insurance, do an assessment and determine the most appropriate product to meet the patient’s needs. You call the insurance company for pre-authorization, get it, and then receive a denial of payment. What next?

January 12, 2017

Online Training for O&P Billing and Administrative Staff

​Century College is offering O&P Office Specialist Courses for anyone already in the field or interested in learning more about O&P coverage, coding and reimbursement.

January 05, 2017

Changes to the Structure of all LCDs Coming

The DME MACs have issued a joint announcement that they will be modifying the structure of all medical device LCDs. ​What are the changes? When are they occurring? How will they affect you? Everything you need to know is in this R&R post.

December 29, 2016

Recap: What Trends to Watch in O&P Reimbursement 2017

​A recent Össur R&R webinar

December 20, 2016

New Knee Brace Codes and Fee Schedule for 2017

​Effective January 1, 2017, the K codes, K0901 and K0902, used for the off the shelf version of knee braces are no longer valid. The codes are being replaced with new codes.​

December 15, 2016

Orthotic and Prosthetic Office Specialist Courses

The Orthotic & Prosthetic Office Specialist course will
equip you with the specialized skills needed in an O&P
office

December 12, 2016

Össur R&R Webinar: O&P Reimbursement Trends to Watch In 2017

Join us for an insightful discussion on trends and predictions for the O&P industry in 2017. Learn how this will impact your practice and what you can do to be prepared.

December 08, 2016

Join OPGA & Össur for a FREE Webinar – Earn 1.5 CEUs

​Join OPGA and Össur's Justin Pratt, ABC CP for a webinar to learn about the latest innovation in prosthetic foot performance.

December 05, 2016

What Trends to Watch In O&P Reimbursement 2017

Össur R&R Webinar​ December 19, 2016

December 01, 2016

Medically Necessary Criteria for Ankle and Knee Braces

In order for an item to be considered for coverage by Medicare, it must be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…” The Local Coverage Decisions (LCDs) give detailed information about medical necessity requirements for various types of braces​

November 29, 2016

Request a Telephone Discussion on Claims Appeals

​C2C Innovative Solutions, the Qualified Independent Contractor (QIC), has been testing a way to get claims in appeal at the ALJ level resolved. 

November 22, 2016

Say Good Bye to the K Codes for Knee Braces

Effective January 1, 2017, the K codes, K0901 and K0902, used for the off the shelf version of knee braces are no longer valid. 

November 15, 2016

Medically Necessary Criteria for Spinal Braces - old

​In order for an item to be considered for coverage by Medicare, it must be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…" The Local Coverage Decisions (LCDs) give detailed information about medical necessity requirements for various types of braces.

November 10, 2016

Webinar Addressing the Effects of Trump's Win on O&P

​NAAOP is hosting a webinar that includes Össur R&R's David McGill. 

November 08, 2016

All About ABNs

​Advance Beneficiary Notice of Noncoverage (ABN) is a form used to notify patients when Medicare may deny payment for an item or service.  Medicare has requirements on when and how to use an ABN.​

November 04, 2016

New RAC Auditor for Orthotics and Prosthetics

​This week, Medicare announced the new contracts for Recovery Audit Contractors (RACs.) ​

November 02, 2016

Lower Limb Prosthetic Covers

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have received a high volume of submitted claims for lower limb prosthetic covers (L5704-L5707) and protective covering systems (L5962, L5964, and L5966) for the same lower limb prosthesis. 

October 25, 2016

Össur Reimbursement Workshop at Össur Americas (Orange County, CA)

During this seminar, you will learn the fundamentals and best practices for billing prosthetics including how to successfully handle appeals. You will learn how to minimize reimbursement risk and the time spent on non-clinical activities, read and understand medical coverage policies, develop a strong letter of medical necessity, and work through the appeals process.​

October 18, 2016

Three Items Needed for a Claim

​Recent audit results from Noridian, Region D DME MAC, indicate three necessary items needed in a file are consistently missing or submitted erroneously. This results in claims denials. 

October 11, 2016

Knee Instability Documentation

The Knee Orthoses Local Coverage Determination (LCD)​ lists the requirements for medical necessity of specific knee braces. One requirement is documentation of knee instability. 

October 07, 2016

New MAC Coding Guidance Re. L5930

The DME MACs issued new joint guidance regarding the appropriate use of L5930 in connection with their review of Otto Bock's C-Leg. What did they conclude and what does it mean for you? Read this post to learn more. ​

October 04, 2016

Off the Shelf and Custom Fit Knee Braces

​Noridian , Region D DME MAC , recently released audit results for Knee Orthoses (KO) . One reason· for denial· is the documentation submitted does not support· the custom· fit· code· billed .  

September 28, 2016

Billing Miscellaneous Codes

​When the existing HCPCS do not adequately describe a product you have the option to use a miscellaneous code. There are specific requirements to include in your claim when using a miscellaneous code.​

September 21, 2016

Federal Court Issues Decision on Delays in Medicare Appeal Process

The U.S. District Court ​for the District of Columbia issued an opinion earlier this week regarding several hospitals' request to compel Medicare to hear and resolve its appeals in a timely fashion. What did it say? What does it mean? Read this post to find out.

September 13, 2016

Are you, or a member of your team, looking to enhance your Orthotic & Prosthetic office skills?

The Orthotic & Prosthetic Office Specialist course will equip you with the highly specialized skills needed in an O&P front office.  This is one of the most comprehensive courses of its kind in the O&P industry, diving deep into Medicare LCD policy, DME MACs, prior authorization, Medicare audits, and more! As a fully online course, it is perfectly suited to fit your busy schedule.

August 31, 2016

What is PECOS?

The Provider Enrollment, Chain and Ownership System (PECOS) is a database of physicians who are enrolled with Medicare. When a physician prescribes an item, such as an OA Knee brace, the supplier must list the physician’s National Provider Identifier (NPI) number on the claim.

August 23, 2016

What if a Patient Returns an Item?

​If you provide an item to a patient and it does not fit properly or function appropriately, you are required to accept the return of the item or provide the necessary repairs or replacements. But what about the patient choosing to return the item for reasons that have nothing to do with quality?​

August 16, 2016

Orthotic Fitter Courses Offered by Össur

​Orthotic Fitter Courses

August 09, 2016

Clean Claims

A clean claim is one that has no defect or omission, including incomplete documentation, that delays timely payment. Of course, that is the ideal situation.

August 02, 2016

What Codes to Use When Billing for Repairs

​When an orthosis or prosthesis has to be repaired, and is no longer under warranty, there are specific labor and parts codes you can use.

July 26, 2016

The Appropriate Way to Give an Upgraded Brace

​Chapter 20, Transmittal 120 of the Medicare Claims Processing Manual lays out the appropriate way to deliver an upgraded device to a beneficiary in conjunction with an Advance Beneficiary Notice.

July 14, 2016

Össur Webinar: Understand the Private Payers Coverage Policies for Bracing

Wed, Jul 27, 2016 12:00 PM - 1:00 PM EDT​

July 12, 2016

OA Knee Bracing: Reimbursement

Our first post provides information about the correct codes and modifiers to use when billing OA Braces. The second post details the specific documentation required to support the various medical coverage policies. Following the guidelines for coding and coverage should logically mean you will be paid for the product, right? In this final post in the three-part series on OA Bracing, we discuss reimbursement challenges.

July 05, 2016

OA Knee Bracing: Coverage

​In this second post of the three part series on OA bracing, we discuss coverage criteria for Medicare and private payers.​

June 29, 2016

OMHA's Plan to Reduce the Medicare Appeals Backlog

On the heels of the GAO's report on the Medicare appeals backlog, the Office of Medicare Hearings and Appeals published its own document setting forth its plan to address the issue. Read this post to learn what OMHA is proposing and how it could affect you.​

June 28, 2016

OA Knee Bracing: Coding

Are you familiar with the coding, coverage and reimbursement issues associated with the Unloader OA knee brace? In this three-part series, we will discuss the basics involved in documenting and submitting Unloader OA knee brace claims to Medicare and private insurers.

June 23, 2016

Last Chance to Register for Webinar: Understanding Private Payers Coverage Policies for LLP

In this webinar, we will review the major private payers coverage policies for LLP, point out unique requirements to meet the definition of medical necessity, and discuss the product categories covered or considered experimental.

June 20, 2016

GAO Issues Report on Medicare Appeals Backlog

The GAO recently issued a detailed report on the backlog of Medicare appeals that has steadily grown since 2011. What does the GAO's data show? What are the implications moving forward? Read this post to learn more.​

June 13, 2016

Össur Reimbursement Webinar: Understanding Private Payers LLP Coverage Policies

In this webinar, we will review the major private payers coverage policies for LLP, point out unique requirements to meet the definition of medical necessity, and discuss the product categories covered or considered experimental.

June 07, 2016

DWO = Detailed Written Orders

​Recent audit results from the Medicare Administrative Contractors indicate that incorrect DWOs account for a high percentage of claims denials.

June 01, 2016

Last Chance to Register: How to Appeal a Denied Claim

Join us for a webinar on Jun 02, 2016 at 12:00 PM EDT

May 27, 2016

Össur Reimbursement Webinar: How to Appeal a Denied Claim

In this webinar, we will discuss the steps involved in filing an effective appeal of a denied claim. We will discuss identifying the denial reason, appeals process, and the basics of writing an appeal letter. ​

May 24, 2016

A Custom Item is Ordered But Not Delivered

​A custom-made item is ordered but not furnished because of (1) the patient’s death, (2) a change in the patient’s condition or (3) the beneficiary cancels the order

May 20, 2016

Prior Authorization is Not a Guarantee of Payment

Your patient is in need of a prosthesis or orthosis. You call the private insurance company to obtain prior authorization. The insurance company phone representative does a review of the case and offers a prior authorization number. You also get a message stating that prior authorization is not a guarantee of payment. What does this mean?

May 19, 2016

You are invited to an Össur Reimbursement Webinar: How to Appeal a Denied Claim

In this webinar, we will discuss the steps involved in filing an effective appeal of a denied claim. We will discuss identifying the denial reason, appeals process, and the basics of writing an appeal letter.

May 17, 2016

Templates and Checklists for Documentation

How many of us take the easy route and use checklists or templates in place of documentation?

May 13, 2016

Complaints About Medicare Advantage Plans

Your patient has a Medicare Advantage plan and tells you he can no longer see you because you are not considered in-network with the plan. Or you are contracted with the plan but experiencing delays in obtaining pre-authorization services. What do you do?

May 06, 2016

Audit Results of Pneumatic Walking Boots

NHIC, Region A DME MAC, recently released results of an audit on pneumatic walking boots billed with HCPCS 4360. The audit showed an overall claim denial rate of 96.7%.

May 03, 2016

Medical Record Documentation Requirements

Can a form or letter signed by the MD be enough documentation for justification or does it need to be in written notes? This is a commonly asked question and the Program Integrity Manual (PIM) provides guidance.

April 29, 2016

Proof of Delivery Requirements per Stephanie Morgan Greene, Esq.

Stephanie Morgan Greene, Esq, provides detailed information on Proof of Delivery requirements.

April 28, 2016

MAC Region A Lower Limb Prosthesis Results

NHIC, the DME MAC for Region A, released its quarterly results for lower limb prosthetics. Read this post to learn what you need to know.​

April 27, 2016

Documentation of Custom Fit Spinal Bracing

​NHIC, Region A DME MAC, recently released results of an audit on spinal orthoses billed with HCPCS L0631 and L0637. The audit showed an overall claim denial rate of 86%.​

April 26, 2016

Orthotic Fitter Courses

Ö​ssur offers orthotic fitter courses. Read this post to learn more.

April 25, 2016

Medicare Appeals Process – Level 3: Administrative Law Judge

Your Medicare claim is denied. You submit a reconsideration request and receive yet another denial. What steps do you take to continue the appeal? This is the third in a three-part post on the Medicare appeal process.

April 21, 2016

Medicare Appeals Process – Level 2: Reconsideration

Your Medicare claim is denied. You submit a redetermination request and receive another denial. What steps do you take to continue the appeal? This is the second in a three-part post on the Medicare appeal process.

 

April 19, 2016

Medicare Appeals Process – Level 1: Redetermination

You submit a claim to Medicare and receive a denial. What options are available to appeal the denied claim? This is the first of a three-part post on the Medicare appeal processes.

April 15, 2016

Region D Focusing on Spinal Orthoses

Region D has announced ​a "service specific prepayment probe review" of numerous L codes describing spinal orthoses. Which ones? What does this mean for you? Read this post to learn more.

April 12, 2016

O&P Separated From DME in the Uniform Glossary

​CMS has finalized a definition of "orthotics and prosthetics" that is distinct from DME in the Uniform Glossary of Coverage and Medical Terms. What does that mean? How does it affect you and your patients? Read this post to learn more.

April 11, 2016

Audit Results for Ankle Foot Orthosis

Noridian, Medicare Jurisdiction D, announced results of a pre-payment audit for Ankle-Foot Orthosis (AFO) billed with HCPCS codes L1960, L1970 and L4360. 

April 07, 2016

Last Chance to Register for the Prosthetic Documentation Webinar

​Join us for a webinar on Apr 08, 2016 at 12:00 PM EDT. ​

April 05, 2016

Coding and Billing of LLP Covers

Lower limb prosthetic covers have specific medical necessity requirements. Your records must document the reason for the cover and the specific uses. This article provides an overview for you.

March 31, 2016

Össur Reimbursement Webinar: Prosthetic Documentation

​Join us for a webinar on Apr 08, 2016 at 12:00 PM EDT. ​

March 29, 2016

Spinal Orthoses - Coverage Requirements

Spinal Orthoses claims continue to be a focus of audits. The DME MAC regions continue to audit for general medical necessity documentation.

March 24, 2016

MAC Region D Prosthetic Foot Review Data

Noridian has published the results of its ongoing review of L5980, L5981 and L5987 claim results. What does the data show? What do you need to know? Read this post to find out.​

March 23, 2016

Join us for a Prosthetic Documentation Webinar

​Join us for a webinar on Apr 08, 2016 at 12:00 PM EDT

March 22, 2016

How to Document Replacement Prostheses

Your patient has been on the same prostheses for several years now. The current device is no longer meeting the patient's needs. When and how do you bill for a replacement prostheses?​

March 16, 2016

Proof of Delivery Clarified

Medicare has issued clarification regarding what constitutes a sufficient description of the item(s) delivered on the required proof of delivery for all claims. What does it say? Read this post to learn more.​

March 15, 2016

Region D, Noridian Will Also Manage Region A

As announced on December 18, 2015, Noridian Healthcare Solutions (Noridian) was awarded and will begin administering the Jurisdiction A (JA) DME MAC contract. Noridian is still coordinating internal processes and will continue to notify the supplier community of updates and timelines

March 08, 2016

Don't Miss Our Webinar: Tips and Resources for Orthotic Claims

​Do you and your staff submit claims for orthotics? Wondering if you are using the correct modifiers or codes? Concerned about justifying medical necessity? Join us to learn about resources available to answer your questions. We will share our top bracing reimbursement tips.

March 03, 2016

Achieving Optimal Prosthetic Outcomes in Physical Therapy

This 2-day offering from Össur Academy will provide education on the treatment & rehabilitation of the lower extremity amputee.

February 26, 2016

RESCHEDULED: Össur Reimbursement Webinar

Due to unforeseen circumstances, this webinar has been postponed until Wednesday, March 9th.

February 09, 2016

Back Brace Audit Results

NHIC, DME MAC, Region A, recently posted results of a pre-payment audit for HCPCS codes L0631 and L0637. These LSO codes describe a lumbar- sacral orthosis that has been trimmed, bent, molded, assembled or otherwise customized to fit a specific patient by someone with expertise. The audit covered 1,511 claims from 398 suppliers processed through September 2015 to November 2015. 

February 02, 2016

Medicare Education and Training Opportunities

​The four regional Medicare Administrative Contractors (MACs) offer webinars and training options for all DMEPOS suppliers. The webinars are presented by the training staff from the MAC, provide an opportunity to learn more about the LCDs and Policy Articles, allow for questions to the MAC staff, and best of all, are free of charge. ​

January 27, 2016

Last Chance to Register: What you Need to Know about Medicare Prior Authorization

​Össur R&R Webinar: What you Need to Know about Medicare Prior Authorization. Open to all clinical and administrative staff.

Thu, Jan 28, 2016 12:00 PM - 1:00 PM EST​

January 26, 2016

Can a Physician Bill for Crutches if Located in a Competitive Bidding Area?

According to the Competitive Bidding Program, Medicare beneficiaries may receive crutches, a cane, walkers or a folding wheelchair from a physician and the physician may be paid for the item under specific conditions.

January 21, 2016

Össur R&R Webinar: Medicare Prior Authorization

What You Need to Know About Medicare Prior-Authorization​​

January 19, 2016

Can a Nurse Practitioner or Physician’s Assistant Write the Rx?

​If a Nurse Practitioner (NP) or Physician's Assistant (PA) works with a physician, can they sign the Detailed Written Order? The Medicare Program Integrity Manual offers guidance.​

January 14, 2016

Webinar: What You Need to Know About Medicare Prior Authorization

Confused by the recently-published Medicare rule regarding prior authorization for prosthetics? Don't know which codes are in play? Unsure of whether prior authorization is a good or bad thing for your business?

 

January 12, 2016

Frequently Asked Questions about Signatures

​The Medicare Administrative Contractors (“MACs”) are cracking down on signatures and certifications.

January 08, 2016

How to Keep Your Money!

​A confusing but important part of the RAC audit process involves appeal deadlines.

December 30, 2015

Prior Authorization for Prosthetics: Final Rule Published

Medicare has published its final rule for prior authorization of certain DMEPOS items, including prosthetics. What do you need to know? Read this post to find out.​

December 22, 2015

Medical Policy Defined

What is a medical policy and why is it important? Read this post to find out.​

December 16, 2015

Region B Posts Spinal Orthoses Prepayment Review Results

MAC Region B just released the latest results of its prepayment review of claims from July-September 2015. Read this post to find out what the data shows.​

December 14, 2015

Last Chance to Register for Össur Reimbursement Webinar

What You Need to Know About Reimbursement in 2016 
 
Join us for a webinar on Dec 15, 2015 at 12:00 PM EST. 

December 11, 2015

Össur Reimbursement Webinar

​Don't Miss Out: Join Us for a Webinar on Reimbursement Trends for 2016

December 09, 2015

Use the Correct Modifier

Modifier mistakes, improperly used or omitted, are the number 1 reason for front end claims rejections. Are you using all the correct modifiers for the HCPCS codes you bill?

December 07, 2015

What You Need to Know About Reimbursement in 2016

Join us for an insightful discussion on trends and predictions for the O&P industry in 2016. Learn how this will impact your practice and what you can do to be prepared. 

December 04, 2015

Addendums to Physician Notes

We have received several questions about addendums to physician's notes. For a detailed explanation of how to best use addendums we go to Stephanie Greene from The Audit Team.

December 03, 2015

Prosthetic Pre-Payment Claim Review Results from Region A

​DME MAC Region A recently published its quarterly results for the ongoing prepayment claim review of K3 prosthetic claims. Read this post for the details.

December 02, 2015

Region A's Prepayment Reviews for Orthoses

The DME MAC for Region A has published the results of prepayment reviews for pneumatic walking boots and AFO's. Read this post to learn more about what NHIC found.​

December 01, 2015

What About Returns of DMEPOS Items?

​If you provide an item to a patient and it does not fit properly or function appropriately, you are required to accept the return of the item or provide the necessary repairs or replacements. But what about the patient choosing to return the item for reasons that have nothing to do with quality? ​

November 20, 2015

Recovery Auditors Start Auditing, Again

​After an almost one year long hiatus, the Recovery Auditors (RA) have been given the green light to start auditing DMEPOS claims again. CMS approved the audits to begin effective November 15, 2015. ​

November 17, 2015

The Medicare Supplier Manual

​In addition to LCDs, Policy Articles, and other articles published by the MACs, the supplier manual is available to assist suppliers with information on supplier enrollment, claims submission, ABNs, documentation, and coding.​

November 12, 2015

Knee Bracing Before Total Joint Replacement Surgery

​Did you know Medicare and the major insurance providers are requiring conservative treatment before authorizing total joint replacement surgery? ​

November 06, 2015

Clarification

Additional information regarding yesterday's post re. PDAC​

November 05, 2015

Does a Product Have to be Listed on PDAC?

We continue to receive questions about the PDAC's role i​n verifying product coding. Here's a primer on what you need to know about this Medicare contractor.

November 05, 2015

Webinar: The Prosthetic Draft LCD: Analyzing Medicare's Decision and Looking at What it Means Going Forward

​Join us for this webinar and discussion.

November 02, 2015

White House Announces CMS Striking Down Draft LCD!

In response to the "We the People" petition created by the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), the White House announced today that the DME MACs will not finalize the draft LCD for lower limb prostheses. What does this mean? Read this post to find out more.​

October 30, 2015

Claims Denied for Inaccurate Delivery Tickets

The Proof of Delivery requires items to be identified by make, model number and a narrative description of the product. 

October 27, 2015

Medicare Advantage Open Enrollment Period

Every year the open enrollment period for Medicare Part C, known as Medicare Advantage, is October 15 – December 7th. What do you and your patients need to know?

October 23, 2015

ICD 10, More Information

By now we are becoming familiar with the new ICD 10 codes. We know the codes address the issue of specificity. O&P providers are required to work closely with the prescribing physician on assignment of the correct code. But what happens when the physician's chosen code is not specific enough? What about the seventh character, which designates initial or subsequent encounter? Read on for answers and links to resources.

October 16, 2015

S.O.A.P. Notes

A standardized format for clinical notes is one way to prepare your practice for claims reviews or audits. The most common form of clinical notes is the SOAP note.

October 13, 2015

Common Claims Denials

A clean claim is one that has no defect or omission, including incomplete documentation, that delays timely payment. Of course, that is the ideal situation. In reality, claims are delayed or even denied for simple errors.

October 09, 2015

Upcoming ICD-10 Webinars

​ICD-10 webinars are open to all DMEPOS suppliers.

October 06, 2015

ICD-10 is Here

On October 1, 2015 the ICD codes replaced the ICD-9 version to a new and expanded version, ICD-10

September 30, 2015

Understanding Denials: Private Payer Claims

One common reason for claim denial is “lack of medical necessity.” Without understanding the details behind this generic denial reason, it is almost impossible to prepare a logical appeal. What resources are available to provide more information about the specific denial?

September 25, 2015

Understanding Denials: Medicare Claims

One common reason for claim denial is “lack of medical necessity.” Without understanding the details behind this generic denial reason, it is almost impossible to prepare a logical appeal. What resources are available to provide more information about the specific denial? 

September 22, 2015

Reimbursement Questions

​Join us for this webinar to get answers to your most challenging reimbursement questions. 

September 18, 2015

International Prosthetic Symposium

Össur Academy is sponsoring an International Prosthetic Symposium November 19-21, 2015 with 8.25 CEUs available.

September 15, 2015

Replacing a Socket

​How often can you bill for a new socket? What documentation is required to justify a socket replacement? These are common questions and the answers are found in the Local Coverage Decisions (LCDs.)

September 10, 2015

Limiting the Scope of Audits

Medicare recently provided clarification to the MACs and QICs regarding the type of issues they can identify for denial when reviewing a claim. The new policy impacts claims with dates of service August 1, 2015 and after.

September 07, 2015

Prosthetic Outcomes for Physical Therapists

​Physical Therapists are a great addition to the prosthetic team and may help provide corroborating documentation. Do you have PT colleagues interested in learning more about prosthetic outcomes? Please share information about this exciting, hands-on training event with CEUs included.​

September 02, 2015

Countdown to ICD-10

On October 1, 2015 the ICD codes will replace the current version (ICD-9) to a new and expanded version, ICD-10. All healthcare providers, including DMEPOS suppliers, submitting claims are required to use ICD-10 after that date.

August 27, 2015

Ground Zero for #NotALuxury: Action in Baltimore and D.C.

​​The DME MACs held an important public meeting yesterday, followed by a rally and a meeting involving high-ranking CMS/HHS officials. What do you need to know about what happened? Read this post.​

August 21, 2015

Draft LCD for Lower Limb Prostheses: Open Comment Meeting

​The process of proposing changes to the LCD requires a public meeting, where interested parties may provide input on the changes. The DME MACs are holding a public meeting regarding the Lower Limb Prostheses LCD on August 26, 2015.​

August 20, 2015

Össur R&R to Participate in NAAOP Webinar re. Draft LCD

Össur R&R to Participate in NAAOP Webinar re. Draft LCD​

August 18, 2015

Signatures and Certifications

​The Medicare Administrative Contractors (“MACs”) are cracking down on signatures and certifications. 

August 13, 2015

Rescind the Draft LCD

Go to www.saveprosthetics.org and sign the petition.

August 10, 2015

Help Spread the Word: Rescind the Medicare Proposed LCD for Lower Limb Prostheses

​The momentum is growing and we are getting our message out. The Medicare proposed LCD for Lower Limb Prostheses is detrimental to those living with limb loss and to our industry as a whole.​

August 07, 2015

Listen Again: Draft LCD for Lower Limb Prostheses

​The DME MACs released a new draft LCD for lower limb prostheses that could replace the current one. The ramifications are potentially far reaching. It is not an exaggeration to say that this might be the most significant change to prosthetic billing and coverage requirements since the creation of the L codes if the draft were implemented in its current form.

August 06, 2015

WE PETITION THE OBAMA ADMINISTRATION TO: Rescind the Medicare proposal restricting access to prosthetic limbs

​Please sign and share the online petition

August 03, 2015

Items Not Covered by Medicare

​If a particular device is excluded from Medicare coverage, it is acceptable to sell it as a cash item and accept payment from the beneficiary at time of delivery

July 31, 2015

Register Now: Ossur R&R Webinar with the latest information on the Draft LCD for LLP

​Join us for a webinar on Aug 05, 2015 at 12:00 PM EDT.

July 29, 2015

Ossur R&R Webinar: Draft LCD for Lower Limb Prosthesis

Join us on this webinar to learn more about the proposed changes and how you can get provide input on the changes. 

July 27, 2015

Common Denials for Lower Limb Prostheses Claims

Region D, Noridian Medicare, recently published an article with common CERT claims denial reasons for Lower Limb Prostheses.

July 24, 2015

Last Chance to Register: How to Appeal Experimental & Investigational Denials

Attend this practical, informative webinar, which will walk you through the key steps you should take to when a claim has been denied as "experimental and investigational." 

July 21, 2015

Draft LCD for Lower Limb Prostheses: How to Comment

​Last week the DME MACs released a new draft LCD for lower limb prostheses that could replace the current one. The ramifications are potentially far reaching. It is not an exaggeration to say that this might be the most significant change to prosthetic billing and coverage requirements since the creation of the L codes if the draft were implemented in its current form.

July 20, 2015

You are invited to a free webinar: How to Appeal Experimental & Investigational Denials

​Attend this practical, informative webinar, which will walk you through the key steps you should take to when a claim has been denied as "experimental and investigational." Learn the proactive strategies to implement, even prior to delivery of the product, to increase your chances of obtaining positive coverage

July 17, 2015

Huge Changes for Prosthetics? The New Draft LCD

The DME MACs just released a new draft of the Lower Limb Prostheses LCD and related Policy Article. What do you need to know? Read this post to find out!

July 14, 2015

Prosthesis Replacement

​Your patient has been on the same prostheses for several years now. The current device is no longer meeting the patient's needs. When and how do you bill for a replacement prostheses?

July 01, 2015

Three Months: Countdown to ICD-10

​ On October 1, 2015 the ICD codes will replace the current version (ICD-9) with a new and expanded version, ICD-10. All healthcare providers, including DMEPOS suppliers, submitting claims are required to use ICD-10 after that date.

June 23, 2015

What to do when you have concerns about the MAC audit process?

​One complaint we consistently hear from providers is about audits. Some have concerns about the number of audits while others are concerned about the overall audit process. CMS has a resource to listen and provide assistance, as appropriate.​

June 15, 2015

What does "PDAC Approved" really mean?

​What does "PDAC Approved" really mean?

June 09, 2015

Replacement Orthoses

​You provided an Unloader One to a patient two years ago. The patient dutifully wears the brace every day and is experiencing significantly less pain. Today the patient returns to your office with a sad story of losing the brace in a flood. Can you bill Medicare for a new L1843 even though the reasonable lifetime of three years has not been met? ​

June 04, 2015

Same or Similar, Part Two

​You have a prescription to provide a brace to a Medicare beneficiary. You check the appropriate DME MAC website to determine if the beneficiary has received a same or similar device in the past. The online record indicates the patient received an identical item two years ago. What do you do now?​

June 01, 2015

Same or Similar

​According to Medicare, braces have a Reasonable Useful Lifetime (RUL) This means that if another brace, which is the same or similar to the one originally dispensed, is provided to the beneficiary within the RUL it will be denied. How do you find out if the beneficiary has received a same or similar device in the past?​

May 26, 2015

Last Chance to Register for Off the Shelf vs Custom Fit code clarification webinar

​Confused about the Off the Shelf versus Custom-Fit codes? 

May 21, 2015

New Pre-Payment Probes for L1940 and L4360

NHIC, Region A, Medicare Administrative Contractor has announced new prepayment probes for AFOs billed with L1940 and Pneumatic Walkers billed with L4360.

May 19, 2015

Medicare Coverage Basics

Medicare has revised its brochure detailing what it does not cover.​ What do you need to know about it? Are there any hidden pearls of wisdom in it? (Answer: yes.) Read this post to find out more.

May 18, 2015

Confused about OTS vs Custom-Fit Codes?

Participate in a  free webinar to review the creation of the Off the Shelf versus Custom-Fit codes, the requirements to bill a Custom-Fit product, and a discussion of the current claim reviews in place.

May 14, 2015

Medically Necessary Criteria for Spinal Bracing - Old

In order for an item to be considered for coverage by Medicare, it must be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…” The Local Coverage Decisions (LCDs) give detailed information about medical necessity requirements for various types of braces.

May 08, 2015

Additional Information on Denials

Your claim is reviewed by the regional DMEMAC and you need additional information about the specific reasons for denial. Read on to learn what tools are available to you.

May 06, 2015

Orthosis LCD Updates

The DME MACs have revised the LCD's for AFO's/KAFO's, knee orthoses and spinal orthoses. What are the changes? How do they affect you? Read this post to find out more.​

May 05, 2015

New Prosthetic Prepayment Claim Review Results for MAC A

MAC Region A published the latest set of results arising out of its review of K3 prosthetic claims. What does the data reveal and how does it affect you? Read on for more info.​

May 04, 2015

Region A Posts New Spinal Orthoses Data

​MAC Region A published the latest results from its prepayment claim review of spinal orthosis claims. Read this post for more information.

May 01, 2015

The OTS/Custom-Fit Difference

The DME MACs have published a new joint publication intended to clarify the OTS/custom-fit distinction. Since this issue continues to confuse people, we revisit the topic in this post.​

April 21, 2015

Last Chance to Register for Free Appeals Webinar

​Join us for "Steps to Succesful Appeals" a free webinar sponsored by Ossur. 

April 14, 2015

Register now for a free webinar: "Steps to Succesful Appeals"

You are invited to a free webinar. "Steps to Succesful Appeals"​

March 31, 2015

New and Improved Reimbursement Resources

​As a subscriber to Ossur R&R, you are able to access valuable reimbursement resources. We recently added new checklists and guides specific to OA & Injury Solutions products.​

March 17, 2015

Supreme Court Expands Agencies' Authority

Why should you care about a Supreme Court decision involving the Department of Labor? Read this post to find out.​

March 10, 2015

What's a referral?

The United States Court of Appeals for the 7th Circuit issued an opinion discussing what a referral is in the context of the Anti-Kickback law? What did they say? Why should this matter to you? Read this post to learn more.

March 04, 2015

Make and Model Numbers Required on Proof of Delivery

​ The DME MACs recently released a joint publication with information about Proof of Delivery (POD) details and requirements. The article clarifies the purpose of the POD and the format of specific items.

February 26, 2015

​A Resource to Assist with your Audit Concerns

​One complaint we consistently hear from providers is about audits. Some have concerns about the number of audits while others are concerned about the overall audit process. CMS has a resource to listen and provide assistance, as appropriate.

February 23, 2015

OIG Issues New Report on O&P Facility

​The Office of the Inspector General released its 6th report analyzing an individual O&P facility. What were the findings? What do they mean? Read this post for more information.

February 19, 2015

​Don’t agree with a Recovery Auditor Determination?

​You receive an audit on one of your claims. Because you are an avid R&R reader, you understand all the required documentation to submit for review

February 16, 2015

Proof of Delivery Clarification

​The DME MACs recently released a joint publication with information about Proof of Delivery (POD) details and requirements. The article clarifies the purpose of the POD and the format of specific items.

December 05, 2014

Back Braces: Audit Results

MAC Region D (Noridian) released audit results from its widespread pre-payment claim review for L0631 and L0637.

February 02, 2015

New Prosthetic Prepayment Results from Region A

Region A released the latest data from its prepayment review of K3 prosthetic​ claims. What does it show? Read this post for all the relevant info.

January 30, 2015

60% of What?

When replacing a prosthetic component, Medicare policy states that one of three possible factors justifying replacement is when the cost of the repair will exceed 60% of the cost of replacement. But what's  the metric for "replacement"? The manufacturer's invoice? The Medicare allowable? Read this post to find out the details.     ​

January 29, 2015

Products Requiring PDAC Coding Verification

​We are continually asked if a product has a “PDAC letter.”What does this really mean and which products actually require coding verification letters?

January 26, 2015

Spinal Orthoses Audit Results

​National Government Services, Jurisdiction B, released results of a prepayment audit on Spinal Orthoses, HCPCS L0450-L0640. The 2014 third quarter audit resulted in a 96.2% claim error rate.

January 20, 2015

Last chance to register for a free webinar on Audits: Myths and Facts

​Join us on this informative webinar with guest speaker, Stephanie Greene, Esq, CPC, from The Audit Team. Stephanie will present the latest information about audits, the myths and facts.

January 15, 2015

New K3 Foot Results from Region D

Noridian has released its most recent prepayment claim review results for L5980 foot claims. What does the data show? Read this post to find out.​

January 08, 2015

Knee Orthoses Audit Results

​Noridian, Region D DMEMAC, just released the results of prepayment audits on HCPCS codes L1832, L1833, and L1843.

January 06, 2015

The Mega-RAC is Here

CMS has announced the award of a new RAC contract. What do you need to know? Read this post to find out the latest.​

December 11, 2014

Ankle Brace Documentation Requirements

MAC Region D (Nordian) recently announced the results of a pre-payment audit for HCPCS codes L1960, L1970 and L4360 for claims submitted between June 2014 - September 2014

December 09, 2014

Last chance to register: The 5 Things Affecting Orthotic and Prosthetic Reimbursement in 2015

​Free Webinar

​Join us for an insightful discussion on trends and predictions for the O&P industry in 2015. Learn how this will impact your practice and what you can do to be prepared.

​Open to all clinical and administrative staff.

November 25, 2014

Proof of Delivery Requirements

​Recently, several questions have come to us about what exact details are required on a delivery ticket, also known as a Proof of Delivery (POD.)

November 20, 2014

Much Room For Improvement in Region D

MAC Region D released prepayment claim review results for two prosthetic foot codes. What did they show? Click here to find out.​

November 18, 2014

Three Things ....

Recent Medicare and OIG news summarized. Review this post to get the details!​

November 10, 2014

Audit Results for Back Braces

​NHIC Corp, Region A DME MAC, released audit results from its widespread pre-payment review of claims for L0631 and L0637. The results, which covered the time frame from January 13 - April 13, 2014, show an overall charge denial rate of 83.3% for spinal orthoses claims.

November 04, 2014

Clarification That Confuses

​Medicare published its final rule addressing the definition of "minimal self-adjustment" on Halloween. What does it say and what does it mean for you? This post tries to cut through the confusion.

October 27, 2014

Region A Hits All Time Low ... And That's Good!

Region A has published the latest quarterly prepayment claim review results​ for K3 claims. Were they good? What do they mean? Read this post for the details. 

October 24, 2014

More on Medicare Advantage Plans

​Last week’s post on Medicare Advantage Open- Enrollment (Medicare Advantage Open Enrollment) prompted thoughtful questions from several readers.

October 22, 2014

K3 Feet in Region D: The Trend Continues

MAC Region D has focused its prepayment claim review activity in prosthetics almost exclusively on K3 feet. What does the latest data show? More of the same. Read this post for our detailed analysis.​

October 21, 2014

Trick Question: What's the RUL for Prosthetic Devices?

We commonly receive questions about the reasonable useful life for prostheses. Just as often, people tell us that the RUL is "x" years. Let's eliminate the confusion once and for all, shall we?​

October 03, 2014

New Recovery Auditors Annual Report Released

Every year Medicare issues a report summarizing the activity of the controversial Recovery Auditors. The FY 2013 data is in - what does it tell us? Read this post to find out more.

September 30, 2014

New K codes…what you need to know to be oK.

Effective October 1, 2014 Medicare has created two new codes describing off-the- shelf knee orthoses: K0901 (single upright) and K0902 (double upright).

September 11, 2014

Last chance to register for the free webinar on "The Basics of Billing Braces" September 16, 2014

​Join us for a free educational webinar on the coding, coverage, reimbursement and billing details related to orthotics.

August 26, 2014

The Basics of Billing Braces

August 21, 2014

Audit Results for Off the Shelf, Custom Fabricated and Custom Fit Braces

​Region D Noridian recently released the results of prepayment reviews for specific Orthoses codes.

August 14, 2014

Small Sample, Bad Results

MAC Region D has published the results of its L5987 review from March through June 2014. It ain't pretty. Click here to learn more.​

August 08, 2014

Ossur Women's Leadership Initiative

Ossur is creating a leadership development group for female O&P practitioners. For more information, read this post. 

August 07, 2014

A Double Dose

A Federal Court dismisses AOPA's complaint against Medicare and the RACs are back. What happened? What does this mean for you? Read on.

 

August 06, 2014

Knee Braces, Back Braces and Region D

​Noridian, Region D contractor for DMEPOS, announced it would begin pre-payment probe audits on Spinal Orthoses (HCPCS L0648 and L0650) and Knee Orthoses (HCPCS L1832, L1833, and L1843.)

July 31, 2014

Number 10 From Region A

​MAC Region A has published its 10th report since 2011 summarizing the results of its ongoing prepayment claim review for K3 prosthetic claims. What did the latest data reveal? Read this post to find out!

July 22, 2014

The Right Way to Give a Custom Brace

Payors only reimburse “medically necessary” care and devices. They don’t cover “quality of life” improvements. To use a vehicular analogy that insurers seem to universally embrace, they’ll provide you basic transportation (Sentra) but if you want a luxury ride (Cadillac), you‘ll have to pay the difference.

So how do you manage the patient who wants the Cadillac?

 

July 15, 2014

1,2,3 for Orthoses Claims Billing

​Do you know what documents you must have in your files prior to submitting a claim?

July 10, 2014

Region D Targeting K3 Feet

MAC Region D published the latest in a series of prepayment claim review reports last week. What did it show? What are the overall trends? Read this post to learn more.​

July 07, 2014

OA Bracing: Reimbursement

This is the third in a three part series on OA Bracing.

June 23, 2014

OA Bracing: Coverage

​In this second post of the three part series on OA Bracing, we discuss coverage criteria for Medicare and private payers.

June 12, 2014

OA Bracing: Coding

​Providing OA Braces to patients is an easy and viable option that provides immediate results.

 
Are you familiar with the coding, coverage and reimbursement issues associated with the Unloader OA Knee Brace?

 

June 06, 2014

Medicare and Prosthetic Prior Authorization: How Would It Work?

Medicare has published a draft rule that would require prior authorization for prosthetic devices. While lots of people are screaming "No!" or "Yes!" in response, what does the draft rule actually SAY? Read on to understand the details. ​

June 05, 2014

PECOS and DMEPOS

​The Provider Enrollment, Chain and Ownership System (PECOS) is a database of physicians who are enrolled with Medicare. When a physician prescribes an item, such as an OA Knee brace, the supplier must list the physician’s National Provider Identifier (NPI) number on the claim.

May 28, 2014

Clean Up Your Claims

​A clean claim is one that has no defect or omission, including incomplete documentation, which delays timely payment.

May 21, 2014

L0631 and L0637 Audit Results

​Region D recently announced the results of an audit on Spinal Orthoses claims.

May 16, 2014

Custom AFOs Audit Results

​Region D recently announced the results of an ongoing audit for AFOs.

May 14, 2014

Walking to Nowhere in Region D

New prepayment claim review results from MAC Region D for one of the K3 foot codes. What were they? What do they tell us? Read this post to learn more. ​

May 08, 2014

The Path to a Successful Claim

What's the best way to get your claims approved? How can you minimize your financial risks? We have a solution for you - read on to find out more.​

April 25, 2014

MAC Region A Q1 Prosthetic Review Results (With Charts!)

MAC Region A has released the results of prepayment claim reviews of K3 prosthetic claims for the first quarter. Any new trends? What do you need to know? Read on to find out.​ Bonus feature: we have CHARTS! 

April 10, 2014

Code Confusion & OTS Orthotics: What Can You Do?

The new orthotic "exploded" codes have created confusion, especially when it comes to items for which the PDAC has previously conducted coding verifications. What should you do? Read this post to find out.

April 07, 2014

Wondering how to document replacement prostheses?

Join us for a free and informational webinar on April 8
presented by The Audit Team.
 

 

April 03, 2014

The ABC's of ABN's

The Advance Beneficiary Notice of Noncoverage regularly provokes confusion and questions from our readers. Here's the quick and easy guide to understanding ABN's.​

April 01, 2014

You are invited to participate in a free webinar focusing on replacment devices

​Prosthetic Claims Documentation Requirements: Replacement Prostheses. Webinar on April 8, 2014

March 28, 2014

Orthoses Defined (Again. Hopefully for the Last Time.)

​After publishing and then rescinding guidance regarding key terms for orthotic L codes, the MACs have now released updated guidance. What does it say? How does it affect you? Read this post to find out!

March 21, 2014

New Prosthetic LCD Update

All 4 DME MACs have published updated Local Coverage Determinations for lower limb prostheses. There's 1 big change you need to know about. Read more to find out what it is.​

March 18, 2014

Ossur Claims Quality Assurance Review Program

​Do you want the security of knowing that your claim contains all Medicare- required documentation before you file it?

March 12, 2014

Region D Clamps Down on K3 Feet

MAC Region D has published the results of its review of L5987 claims. What was the claim error rate? What will Region D now do? Read this post for the details.​

March 11, 2014

Last Chance to Register: Lessons Learned: Audits, Appeals and How They Impact Bracing

​Auditors are increasingly focusing on bracing products and denying payment on claims. Join us for this informational webinar to learn about the current audit situation, what you can do to increase your chances of a successful audit, and how to appeal your bracing claim denials. The webinar is offered free to Ossur customers.

March 08, 2014

Orthotics Undefined

More guidance from the MACs about the definitions for orthotic codes. Can you say, "180"? Read this post for more.​

March 06, 2014

Lessons Learned: Audits, Appeals and How They Impact Bracing

​Auditors are increasingly focusing on bracing products and denying payment on claims. Join us for this informational webinar to learn about the current audit situation, what you can do to increase your chances of a successful audit, and how to appeal your bracing claim denials. The webinar is offered free to Ossur customers.

March 03, 2014

Proof of Delivery 1-2-3

Are you complying with all the requirements for a valid proof of delivery? Any oversight may result in a claim denial.

February 28, 2014

Orthotics Redefined

​Medicare Administrative Contractors issue clarification on codes.

February 20, 2014

A Temporary Reprieve

CMS announced changes to the RAC program. How will this effect your business? What are the changes? Read more to find out.​

February 19, 2014

Same and Similar

The January 29, 2014 post “Life Expectancy” prompted several questions about how to determine if a patient has received the same or similar device in the past. There are steps to follow increase chances of a positive payment.

February 13, 2014

The OIG's Road Forward

OIG has released its 2014 Work Plan. What's in it? How will it affect you? Read this post for all the details.​

February 11, 2014

New Audit Issue…Watch Your Back

The Region A Recovery Auditor has posted a new issue for review:  “Spinal Orthoses: Thoracic Lumbar Sacral Orthoses and Lumbar Sacral Orthoses.”

February 10, 2014

Back by Popular Demand

Join us for this encore presentation of a webinar on the documentation needed to appropriately support prosthetic claims in case of an audit. Stephanie Greene from The Audit Team will present an actual case study complete with examples of notes, forms and reports.

Sponsored by Ossur.

The previously recorded webinar will be presented.

February 05, 2014

Four for Backs

​Jurisdiction D, Noridian, has announced the latest results for its Spinal Orthoses prepayment review (codes L0631 and L0637).

February 04, 2014

New Year: New Resources

Always looking to improve, Ossur R&R offers you 5 new and improved Reimbursement Guides. Check out this post to learn what they are and why they're better! ​

January 30, 2014

Region D's Bad AFO/KAFO Scores

MAC Region D just released new prepayment review results for AFO/KAFO claims. The data isn't pretty. What do you need to know and what does it mean?​

January 24, 2014

Oh-fer

MAC Region D has published the results of its prepayment review of L5981 claims. Very small sample. Very poor results. Read the post to find out more. ​

January 23, 2014

New Year, Same Issues in Region A

MAC Region A just published its latest prepayment review results for K3 prosthetic claims. What do you need to know? We've got the answers in this post.​

January 22, 2014

Webinar Invitation: Join us for "Prosthetic Claims Documentation Requirements: A Case Study"

Final day to register.
 
​Join us for this informational webinar on the documentation needed to appropriately support prosthetic claims in case of an audit. Stephanie Greene from The Audit Team will present an actual case study complete with examples of notes, forms and reports.

January 20, 2014

More on the New Codes

​As we stated on December 9, 2013 in the R&R Bulletin, Medicare has modified the language of 23 already-existing L-codes to add the words, "prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise" to the end of the description.

January 17, 2014

A PECOS Resource

Since our ​December 12th post on PECOS, we have learned of a tool that you may find useful. Read more to understand what it is, how it works, and where you can find it.

January 09, 2014

Cleaning up documentation s-o-a-p

​A standardized format for clinical notes is one way to prepare your practice for claims reviews or audits.

January 07, 2014

More Ways to Get Paid in 2014

​With the New Year comes new deductibles and benefit plans.

December 19, 2013

2014 Fee Schedule Update - Things Come Into Focus

Medicare has released the 2014 fee schedule. In this post, we break down the most important things you need to know.​

December 12, 2013

New "Dear Physician" Letter: PECOS is Coming!

The Medicare Administrative Contractors have issued a new "Dear Physician" letter. What does it say? What does it mean for you? Read this post to find out.​

December 09, 2013

2014's New and Modified Codes - What You Need to Know

Medicare has released the 2014 HCPCS Code Set. Big changes in orthotics are looming, and there's news on the prosthetic side as well. What do you need to know? Read on to find out. ​

October 31, 2012

‘Tis the Season….for enrollment in Medicare Advantage plans

November 19, 2013

​Bowling for Denials

At least one Recovery Auditor has adopted a novel approach to K level determinations. What is it? How do you fight it? Read this post for the necessary information.​

November 18, 2013

Ask the Össur Orthotics Reimbursement Expert

​ Free webinar scheduled for December 6, 2013 at 1pm EST.

November 15, 2013

Maintain Your Standards

Medicare ha​s a lengthy list of Supplier Standards you need to comply with. Do you? In this post we give you a summary of 6 of the often-overlooked/misunderstood standards.

November 08, 2013

A Solution for Your Claims Problems

Are your Medicare claims getting denied during prepayment review? Are you losing money to Recovery Auditor clawbacks? Are you not sure if your claims satisfy payer requirements? We have an answer for you.​

November 07, 2013

Four Reports, One Interpretation

The OIG just released the 4th report since July about MACs' processing of lower limb prosthetic claims. What should you take away from this systematic dive into the world of O&P by the OIG? Read this post for our intrepretation. ​

November 06, 2013

A New Audit Issue

​Region C has published a new audit issue that, while focused on hospital and physician claims, may have a significant impact on orthotic claims

October 28, 2013

When Scoring Less Than 50% is a Good Thing

New results from MAC Region A on its widespread prepayment review of lower limb prosthetic claims. There's some good news and some bad news. To learn about both, read this post!​

October 25, 2013

Proof of Delivery

​Results of a recent audit by Region D indicate that a significant percentage of Orthoses claims had incorrect Proof of Delivery documentation. The MAC denied claims based upon the missing information.

October 23, 2013

A Painful Probe in Region D

MAC Region D announces new results from a prosthetic foot widespread prepayment probe review. Here's the info and what it means for you.​

October 22, 2013

Coverage Requirements for Spinal Orthoses

​MAC Region D has announced the results of an audit of Spinal Orthoses with HCPCS codes L0637 and L0631.

October 21, 2013

Done.

The updated and corrected POWER KNEE Reimbursement Guide is now available for download.​

October 18, 2013

Update to our Update! Important!

We're making edits to the recently-updated POWER KNEE Reimbursement Guide that we released earlier this week. Learn why.

October 17, 2013

All About Audits

​Today is the last chance to sign up for the "Ask the Audit Expert" webinar scheduled for tomorrow, October 18, 2013 at 1pm EST.

October 15, 2013

High Horsepower Reimbursement Support

Ossur has updated its Reimbursement Guide for POWER KNEE. Read more to understand what's new.​

October 14, 2013

Reimbursement Support in a Vacuum

​Ossur's Reimbursement guide for its Unity sleeveless vacuum system is now available for download.

October 10, 2013

Modifiers

Specific products and product categories require the use of one or more modifiers in order to make the claim eligible for payment.

October 08, 2013

Guilt By Association

Medicare recently published its Fee-for-Service 2012 Improper Payments Report. What are the implications for O&P? Read on to get our take.

October 02, 2013

A New R&R Resource For You!

Ossur unveils its latest downloadable tool to help you address reimbursement challenges.​

October 01, 2013

One, Two….

Prosthetic claims that include a second liner are being denied.

September 24, 2013

They're Looking at Your Feet!

MAC Region D announces a new prepayment review of certain K3 feet.​

September 11, 2013

A New OIG Report ... On MAC Region D

OIG has issued a new report on MAC Region D. While the report has a few interesting facts, equally relevant is Region D's response back to the OIG. Here's what you need to know.​

September 05, 2013

A New OIG Report ... On RACs

OIG just published a new report on the RACs. What are the key findings? What does it mean for O&P?​

September 04, 2013

Alphabet Soup: HCPCS & PDAC

What's the difference between different entities involved in L-codes? Here's the quick and easy explanation.​

September 03, 2013

L5930: What You Need to Know

We continue to get regular questions about the appropriate use of L5930 (“high activity knee control frame”) from prosthetists around the United States. While Medicare’s guidance about this code qualifies as “old news,” we thought a quick and clear description of the applicable requirements would help.

August 28, 2013

Are you bracing yourself?

All four DME MACs have announced a revision of the LCD for knee bracing. The new version includes coverage criteria for ruptured tendons.

August 27, 2013

Nobody Likes Rejection

​According to MAC Region A, the top reasons for claims rejection involve modifiers. Invalid or missing modifiers may cause claim rejection.

August 22, 2013

Back to Basics: The Prosthetic LCD (Part 4)

The final installment in our series reviewing the key elements of Medicare's Lower Limb Prostheses LCD.​

August 18, 2013

OIG Finds Fault with Region A

A new OIG Report on lower limb prosthetic claims may portend continued scrutiny of these claims moving forward.​

August 16, 2013

Back to Basics: The Prosthetic LCD (Part 3)

​In Part 3 of this series, we review the LCD's treatment of "general" (Medicare's term, not ours), feet, knees, ankles, hips and sockets.

August 15, 2013

Back to Basics: The Prosthetic LCD (Part 2)

​In Part 2 of this series, we look at the LCD's discussion of functional levels.

August 14, 2013

Back to Basics: The Prosthetic LCD (Part 1)

In Part 1 of this series, we explain Section 1 of the Lower Limb Prostheses LCD, which addresses coverage indications, limitations and medical necessity.

August 06, 2013

R-E-S-P-O-N-D

August 02, 2013

When 99% is not good….

July 31, 2013

Back starts with B

July 25, 2013

Some RAC Slack?

Anecdotal evidence that Medicare has instructed the RACs to shift their auditing focus.​

July 21, 2013

New OIG Report re. MAC Region C Claims

What does OIG think of Region C?

July 16, 2013

Claim Adjustment Reason Code 223 Explained

June 17, 2013

MAC Region A Results: Remember to Touch all the Bases!

MAC Region A's new prepayment claim review results for early 2013 reveal that prosthetic suppliers continue to struggle with basic documentation requirements.​

June 14, 2013

Why CMS Fraud Prevention Efforts are Here to Stay

​New data from HSS showing increased success in combating fraud will likely increase scrutiny of claims in the future.

June 13, 2013

The Right Way to Give Your Patient More

Payors only reimburse “medically necessary” care and devices. They don’t cover “quality of life” improvements. To use a vehicular analogy that insurers seem to universally embrace, they’ll provide you basic transportation (Sentra) but if you want a luxury ride (Cadillac), you‘ll have to pay the difference. So how do you manage the patient who wants the Cadillac?

June 06, 2013

A Takes a Step Forward

​Performant Recovery, the Recovery Auditor for Region A, recently posted a new audit issue, listing certain HCPCS codes that cannot be billed with pre-fabricated AFOs and KAFOs.

June 03, 2013

Getting Better in B?

​MAC Region B error rate falls by more than half. But close to half of all claims still getting denied. Why?

May 28, 2013

The Heat is BACK

​MAC Region D releases information about audit of spinal orthoses claims. They denied the majority of claims for not meeting medical necessity requirements. What does this mean for your practice? 

May 24, 2013

The Template Meeting You Should Attend!

​Why you need to attend Medicare's Open Door Meeting Tuesday, May 28, 2013.

May 22, 2013

The Solution to Medicare-Compliant Claims

​Ossur has partnered with HMG/The Audit Team, a company whose principals have more than three decades of experience in the world of O&P and DME. With a staff of experienced coding, clinical, and legal personnel, The Audit Team now offers its Quality Assurance Review package for Ossur's Bionic products. ​

May 21, 2013

How Gifts Can End Your Career

​As government scrutiny of health care generally, and O&P specifically, explodes, you need to carefully consider the "freebies" offered to you and the risks they pose. As the government's recent case against Orthofix proves, taking gifts can put your business at risk today and you in jail tomorrow.​

May 21, 2013

A New Template for O&P

​The Centers for Medicare and Medicaid Services have posted a draft Lower Limb Prosthesis Electronic Clinical Template on its website. The four-page document "describes the data elements that CMS believes would be useful in supporting the documentation requirements for coverage of Lower Limb Prostheses."​

May 14, 2013

Keep on Learning

May 09, 2013

Oh-Fer For O&P

May 06, 2013

L5930: Ancient History You Need to Know

May 02, 2013

AFO Prepayment Audits...continued

April 25, 2013

Another Way to Get Your Medicare Claim Denied Part 2: Delayed!

April 22, 2013

Competitive Bidding Round 2: Key Facts

April 19, 2013

May 1: Another Way to Get Your Medicare Claim Denied

April 18, 2013

Our Error

April 03, 2013

A Follows B

April 01, 2013

2% Less

March 25, 2013

Back to Back

March 19, 2013

New Audit Issue…Watch Your Step

March 18, 2013

New Name, Same Game

March 11, 2013

Region A Says Prepay Prosthetic Reviews Here to Stay (For Now)

February 21, 2013

More Info Required

February 07, 2013

The RAC Annual Report: Behind the Headlines

February 07, 2013

New and Improved

February 05, 2013

The Coding Revolution

January 30, 2013

Clarification from MAC Region B: "Hold on a sec!"

January 28, 2013

Check Your Feet!

January 10, 2013

To be continued

January 07, 2013

Updates to Spinal Orthoses LCDs effective January 1, 2013

January 02, 2013

Important Medicare Billing Info for 2013

December 21, 2012

Severe Back Pain

December 19, 2012

A Few Steps to Assist in AFO Claims Submission

December 17, 2012

Physician Documentation: One Region’s Guidance

December 11, 2012

Up. Down. Left. Right.

December 10, 2012

Time is Money…

Jan/09/2014

Cleaning up documentation

November 30, 2012

The Medicare Policy Manual: What You Have to Know (Part 1)

November 29, 2012

The Economics of Insurance Companies

November 12, 2012

Relief and Call to Action

November 06, 2012

The 2013 L-Codes: A Summary

October 26, 2012

The Error of Your Ways

October 15, 2012

Cover Your Back

October 12, 2012

OIG Report Examines Medicare Payments for Prosthetics and Custom Orthotics

October 03, 2012

Important Miscellaneous Information

September 28, 2012

Blue Card Changes

September 21, 2012

“We're Not Gonna Take It Anymore”

September 20, 2012

The Power of the Appeal

September 12, 2012

ABNs Again

September 07, 2012

Code Cracking

September 01, 2012

Consolidation is a Side Effect of Health Care Reform

August 28, 2012

Ten things to remember about TENS Device

August 24, 2012

Running the Functional Level Gauntlet

August 17, 2012

The Quest for Legible Signatures

August 13, 2012

Region D Initiates Prepayment Review for Prosthetic L Codes

August 09, 2012

PDAC Requirement Reversed: Is it Really a “Win”?

August 08, 2012

PROPRIO FOOT Coding Explained

August 02, 2012

Public-Private Cooperation Spells Higher Risk for Providers

August 01, 2012

Össur R&R – An Introduction