Coding vs Reimbursement Part 1
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Over the past few decades one of the most common questions posed by most providers is how do I code for a … so I can get paid for?
That “innocent” question is anything but and really opens a pandora’s box to many issues….
The short answer is that you are actually asking two questions. One is a coding question and the other is a matter of reimbursement. And these are not the same. They are two separate and distinct questions. Let’s explore what those terms really mean, using the foot orthotics provider as an example.
Correct coding for any provider indicates that service or product provided is properly represented by the CPT or HCPCS code submitted for reimbursement consideration.
Reimbursement is a whole different matter, and it refers to whether that CPT or HCPCS code is reimbursable and under what circumstance.
Let’s look at one simple example, foot orthotics, of which there are several types, custom fabricated, custom fitted, and over the counter. Looking at one custom type of custom fabricated orthotic is a UCB type device, properly represented by L3000.
Let’s assume that your device meets the definition of custom fabricated, interpreted as made from a negative image of the patient’s foot and made from raw materials. Furthermore, it one reviews many of the accepted coding texts, this device has rather deep heel cup and is made of rigid materials. One then can assume that the correct coding is L3000. But there are more questions which may need to be answered prior to understanding whether or not the product you dispensed is reimbursable.
How deep is the heel cup? How rigid must the device be? How often can the patient receive such a device? What is the reimbursement? What is the date of service (the date of casting or the date of delivery)? Those may appear to be coding questions, but instead these are really reimbursement questions. These may differ from carrier to carrier and even within the carrier from policy to policy and from State to State.
In Part II of this two-part article, we shall delve a bit deeper into the reimbursement aspect…
