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I coded and billed for CPT 97763, Orthotic Management, and training for a Medicare patient who was dispensed a pair of custom foot orthotics. While the patient did not meet the criteria for the foot orthotics since the orthotics were not being placed into a shoe attached to a leg brace, can I still bill for the management and training?

No. Only time spent on the day of the patient’s encounter can be counted towards the time spent with the patient. Additionally, reviewing labs, outside reports, consultations, speaking with physicians, or providing coordination of care on the day of the encounter can be counted towards the time spent and the level of E&M coded for.

If I am reviewing a patient’s chart the day before since I know it is going to be a complicated visit, knowing an increased amount of time will be spent with the patient, am I entitled to bill for that?

No. The provider that sees a patient must be credentialed by the carrier in order to bill for the services. The NPI for the provider who provides the services is placed in box 24J on a HCFA-1500 form. The provider can’t provide these services under any special agreement such as locum tenens.

If my associate sees a patient and they are not credentialed by the insurance plan that the patient has, can the claim be submitted under my name and NPI number?

They are correct in that Medicare requires the patient to be under a comprehensive plan of care for diabetes. If the primary care physician or their PA or NP is referring the patient to an endocrinologist for treatment of their DM, then the PCP is correct. You need to coordinate with the endocrinologist’s office.

My patient’s internist refuses to agree/attest to my documentation. They say they are not treating the patient’s diabetes, and I should communicate with the patient’s endocrinologist. What should I do?

Assuming the wound site receiving the CTP is the same site that is being debrided, It is assumed that the wound recipient site is ready for the application of the CTP. Any minimal site prep of the wound is already included in the application of CTP. In the unlikely scenario that the site that is being debrided is a different site than that receiving the graft, can these two be billed on the same date of service

Can I bill a debridement code (1104X or 9759X) on the same date as the application of a cellular tissue product?

The response provided by Dr. Freedman is very thorough and quite accurate.Most third party payers adapt Medicare Fee For Service policiesbecause they do not want to cover the costs of developing their own policies which have already been vetted by the medical directors for the four DME MAC. Most third party payers cover themsevles by burying somewhere in their policy documents the following type of statement: Unless otherwise noted , please refer to Medicare reimbursement policy guidelines for coverage information. These types of statements DO NOT necessarily have to be stated in the specific DME (or medical/surgical) policy. They may often be found in the operational guidelines of the carrier. This can be frustrating and may be difficult to find. Because of the generality of the statement, you may only see different coverage for (in this case BC) if that exists. Otherwise in the absence of any statements indicating coverage, one should assusme the carrier’s coverage is reverting to the DME MAC policy. Since the four DME MAC all share the same exact policies, it is rather easy to figure out the coverage policy of payers other than FFS Medicare. My suggestion would be in the future for all DME related matters on non Medicare carriers, to assume they follow the DME MAC rules, unless you can find otherwise. The only sure fire way unfortunately is to call their customer service line. You may be wise to call twice to affirm you are getting the same answer. And of course preserve the name time of the rep. their employee ID and log ID of the call.

It is my experience that Achilles Tendonitis is not a covered reason, I believe they follow CMS guidelines on this one. It would be plantar fasciitis M72.2 or Contracture diagnoses. The following is from the DMERC Noridian which I feel would be applicable even though BCBS Carefirst did not have this posted on their site. An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met:Plantar flexion contracture of the ankle (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and, Reasonable expectation of the ability to correct the contracture; and, Contracture is interfering or expected to interfere significantly with the beneficiary’s functional abilities; and, Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons. The beneficiary has plantar fasciitis (refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses).If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home). Covered Diagnoses: M24.571 Contracture, right ankle M24.572 Contracture, left ankle M24.574 Contracture, right foot M24.575 Contracture, left foot M72.2 Plantar fascial fibromatosis

Question: I received 2 denials this week from my BCBS, it was about using my diagnosis Achilles Tendinitis with my L4397, why? What is your advice when I appeal this?