Coding vs Reimbursement Part 2
-
In Part 1 we presented an overview of coding and began to ask some questions about reimbursement. Now let’s dive a bit deeper into a bit more of the orthotic reimbursement issue…
The most glaring example is a traditional fee for service Medicare patient who receives a UCB type foot orthotic. These are properly coded as L3000, but foot orthotics are not reimbursable (GY) unless placed into a shoe which is an integral part of a leg brace.
In another example, assuming state law guarantees foot orthotic coverage, carriers may require the heel cup to meet specific heel cup depth and specific durometer requirements in order to meet reimbursement requirements for L3000. Hence even though state law in that state requires insurance carriers cover an adult for two pairs of foot orthotics per year, unless the device meets certain specifications, your L3000 may be downcoded to other custom fabricated foot orthotic codes (L3010 or L3020) or outrightly rejected.
Another glaring example are two national carriers which also almost never cover foot orthotics in their National policy. However, these policies do allow for exceptions (e.g. retired Federal workers). These carve outs may allow for coverage but may limit how often and may additionally have a narrow provider network, from which you are excluded. These types of exceptions for coverage typically occur when the carrier is simply acting as the policy administrator and the coverage was underwritten by the entity providing such coverage (e.g. union, employer, etc.).
As one can see, understanding the coding for foot orthotics is simpler than foot orthotic reimbursement. This may seem confusing, especially to those new to foot orthotic billing, But there is a sure-fire way to make things easy and determine in advance whether your patients are covered for foot orthotics. By following these simple six steps you can be assured of coverage or letting your patients know they are financially responsible for orthotic coverage:
- Never assume two patients with the same (or similar policy from the same carrier are both covered). Always obtain a copy of the carrier’s policy. Under HIPAA and full disclosure laws, policies must be readily available to patients and providers. Inquire with every patient’s third-party payer about coverage.
- Be sure your documentation adheres to the policy parameters. Do not take short cuts and do not leave the documentation to others.
- Pre-authorization alone may not be enough, as many carriers may not require pre-authorization of benefits for foot orthotics. Even, if necessary, prior authorization does not guarantee payment.
- To guarantee coverage ask for an organizational determination of benefits (aka pre-determination of benefits). These assure you that on a specific date with a specific diagnosis and HCPCS code that the patient is in fact covered. This is not subject to future determination at the time the claim is submitted and is an iron clad guarantee of coverage. Carriers can typically attempt to weasel out of payments even after with a prior authorization. However, with the exceptions of instances of fraud, third party carriers cannot deny claims after your practice has obtained a pre-determination of benefits.
- Be upfront with your patient. Get them involved in the determination of organizational benefits. The fact that orthotics are not a covered service by their third-party carrier does not negate their medical necessity. Many providers are ecstatic that foot orthotics remain fee for service.
- Set a positive tone for your patient. There is a great deal of psychology to assure patients will be successful with orthotic therapy. But you must set the correct tone!
Repeat these steps for all your patients regardless of whether you are certain of their coverage status. It’s been my experience that patients who know you are genuinely interested in more than their clinical issues (e.g. financial) are more likely to have positive outcomes, regardless of the recommended therapy. Going the extra mile for your patient will almost always assure you will be properly compensated regardless of coverage.
- Never assume two patients with the same (or similar policy from the same carrier are both covered). Always obtain a copy of the carrier’s policy. Under HIPAA and full disclosure laws, policies must be readily available to patients and providers. Inquire with every patient’s third-party payer about coverage.
