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This is a very complex subject and the response is intended only to provide a very broad response.Before you even consider doing telelmedicine, consider: Were you and the patient in the same state where you are licensed or in different states and are you licensed in the state where the patient lives?Are there any limitations based on the interstate compact which preclude you from performing telemedicine?If none of these are problematic, then consider other factors. The total time you spent on line with the patient is crucial to be documented and can easily be documented by the time the visit was initiated and terminated. These should be accompanied by your signature attestation. Why you could not see the patient in person and perhaps even more important, is why the patient could not come to your office is secondary but nevertheless should be documented as well as who initiated the virtual visit. Was the virtual visit audio only or audio and video and what platform software platform was used? All other E/M components as if you saw the patient in your office are also important.Some components to go a step further, for example would be if the patient’s vitals were to be taken, did the patient have a BP cuff and was it done while you observed? What did you observe about the patients ROM?Did the patient show you snap shot of their blood glucose from the past ten day? In other words how did you come to the understanding of certain findings needs to be documented.Some providers even record the audio/video interaction and download it into the patient’s file. From the payment status, depending on the carrier, some pay the same for physical and digital encounters others pay less for virutal visits. Some relaxed co payment rules others did not. For certain telemedicine visits specific modifiers are required on the claim form and use the same E/M CPT codes as for physcial encounters. It is important to understand that many other rules were relaxed during the PHE to allow patients greater access to their doctors. This includes rules regarding HIPAA, locations for both patient and provider and more. The termination of these relaxation rules may no longer afford you the ability to perform telemedicine using non HIPAA compliant platforms such as facetime, zoom, or other free (or almost free) popular video platforms.And most important, the geographic (urban vs rural) may also revert back topre pandemic status.I would suggest you follow this forum for future updates on Telemedicine as this is a constantly evolving issue.

I do a great deal of telemedicine in my practice and am currently being audited. What are the most important things to document?

There are significant functional differences between the Xtern (PDAC L1951) braces with them having various features. My advice would be to discuss these differences as they apply to your patient. Since the devices are custom fitted (PDAC O2 category), there are no additional HCPCS codes which are allowed to be billed. There are also some Xtern braces which are validated as L1932 which pay higher than the L1951.Any additional fees you incur for additional add on’s you order for either coded brace, do not have a separate HCPCS code which can be billed to either Medicare (FFS) or Medicare Advantage plans. However, since all Xtern braces attach to the shoe, if a foot orthotic device is required on the brace side, it is reimbursable under the Orthopedic Footwear policy. The rationale is that under this policy, foot orthotics are covered when they are placed into a shoe which is attached to a brace. The appropriate L-Code for the orthtoic would be first amended with the KX modifier and second with a site modifier (LT or RT). Also the contralateral limb which does not have a brace, if it requires a foot orthotic, will not be covered by traditional Fee for Service Medicare (and likely not by Medicare Part C Plan).That is a cash service and the L-code for that side would be amended with GY (statutorily not covered) as the first modifier and second with a site modifier (LT or RT). Note that the payment limitations cited above (surcharge for additional features you add to the Xtern) are limited to only Medicare recipients. One would need to check the patient’s third party coverage if they are not Medicare beneficiaries.

The answer is NO, as stated they are both PDAC L1951.

The new XTERN Summit is a carbon brace, and the provider pays the product vendor hundreds of dollars more for it than for the XTERN classic, which is made of plastic. Both are PDAC-certified L1951. Because the XTERN summit costs the provider more, can the provider charge the patient cash for the difference in cost if the patient wants the carbon brace over the plastic brace?

Under the split-shared rules, the provider who sees the patient for a majority (>50%) of the time is the one who is entitled to bill for the visit.

I see a patient in the hospital along with the nurse practitioner who has also seen the patient. Who is entitled to bill for the services?

You are correct in that Medicare’s LCD and PA most often do not cover devices to offload ulcers other than diabetic shoes or crow boots. This seems archaic to cover nothing between a $300 pair of shoes with inserts and a $2,000 Crow boot. But this is the policy. CAM boots (e.g. L4361/L4387) if used to treat and stabilize a foot deformity ( e.g. Charcot) or fracture (often associated with Charcot) no doubt would qualify for coverage. So might a plantarflexed metatarsal, but you would need to be able to establish medical necessity for whatever you are providing.

My CTP LCD stipulates that I must offload a DFU, yet the DME policy does not recognize offloading as a covered diagnosis. What should I do?

Wastage is a big issue for CMS and its contractors. Technically most of the LCD and PA stipulate that providers should attempt to use a CTP that comes as close as possible to the recipient site. Blatant disregard to this will likely get you into some trouble. In any case, one should be very specific in choosing any specific CTP and document the rationale the specific CTP and size was chosen.

The sales representative from a specific company is telling me that I can only buy one size of a specific graft because that is the only available size. They tell me I can bill whatever is not used as wastage. Is this correct?

If you feel very comfortable answering their questions, by spoon feeding them exactly where the information is in your medical record stating they must have overlooked the information then you’re detailing the answers only helps to win. If you do not feel comfortable answering, do not take it into your own hands, hire a professional who handles appeals.