Search Results

Part II on PA program. It is noteworthy to understand that an affirmative PAR decision follows the patient not the provider. Supplier A could have done all the work to obtain the PAR and the patient can choose another provider to supply them with the DMEPOS. Be careful if a patient has obtained a PAR approval with another supplier. As you may still require all their documentation if you are subject to either a TPE or post payment review.Thus if you find yourself in this position (within the 60 day window), do not submit another PAR as it may l be denied as a duplicate Instead contact the other supplier and obtain all the information they submitted to Medicare. If a PAR is continued to be denied, you have several choices. 1. Refuse to provide the service and find an alternative meeting the patient’s needs 2. Have the patient sign a very specific ABN. Theclaim would need to be amended with the GA modifier.

The Medicare DMEPOS prior authorization is based on specific HCPCS codes which are posted on a “DMEPOS Master List”. These can be found on any of the DME MAC websites on the CMS website at Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment | CMS For podiatrists, the only AFO currently listed requiring a Prior Authorization Request (PAR) is for L1951 a very specific custom fitted AFO. The PA program by regulation must either provide you with an affirmative or non affirmative response within 5 business days for a standard PAR or 2 business days for an expedited PAR. In the case where the patient has an emergent need for a specific device, as in the case of a bad sprain or fracture, the HCPCS code can also be amended with an ST (Stat) modifier. This will allow your claim to by pass the mandatory PAR edit. However, it will more than likely result in the claim being subject to a pre-payment review.This will allow the provider to dispense a product without having to wait for a response from the DME MAC, but not without having the possiblity of having the claim denied if the documentation on review does not support medical necessity. Your DME MAC within the alloted time will send you an affirmative decision with a Unique Tracking Number which can be affixed to the claim. Your EHR vendor should be able to assist you with this. For claims deemed as non affirmative for lack of medical necessity you can submit additional documentation via the portal endless number of times. All PAR decisions are good for 60 days and the patient must be provided with the DMEPOS within 60 days of the affirmative decision. Your EHR and all supportive chart documentation can be uploaded to the provider portal (NMP for DME MAC A or D or MyCGS for DME MAC B and C) by using the Prior Authorization Button.You can also track the progres through the portal by doing a PAR inquiry. There are also other PAR requirements for bone stimulators (both electromagnetic and ultrasound) which were to go into effect later this month, but have now been postponed until Mid September. There are other PA programs either currently or soon to be implemented, however DPMs generally prescribe and do not dispense these services. The bottom line is whether you dispsense or only prescribe, your supportive documentation will be subject to more scruitny. Any vendor if also the DMEPOS biller will definitely want to secure and review your documentation before they provide your patient with any product subject to a PAR. I would urge you to review the CMS website listed towards the top of this posting and also search your DME MAC webpage for more information.

I understand that Medicare now has a prior authorization program for certain DMEPOS. How will that effect me and my patients? - WoodsideDR

Great question. Both off the shelf and custom fit devices are considered prefabricated. But what matters most to Medicare is what you did as a qualified health provider, at the time of delivery. If you did something a lay person could do then the device is not custom fit.If the device was prefabricated but rendered “custom” to some degree by the lab, that’s not enough. You must do something more, to make it qualify under Medicare’s rules as custom fit. Medicare provides examples such as did you bend, mold, heat, or grind the device so as to make it fit uniquely fit the patient.Another example is if you took some prefabricated components and installed them onto the device in order to make the device fully functional.One example are for external AFO’s which attach to the shoe.They must have a special clip attached to the shoe in a specific place and in a certain manner. The clip may need to be bent and then secured to the shoe. Often times a heat gun to bend and/or widen the heel area of the brace to ensure a proper fit onto the shoe may be required. These all go beyond the Medicare rule of "Limited Self Adjustment. This rule basically applies to modifications which any layperson can do. Adjusting a strap is one example. To summarize: What you did as a qualified health care professional in your office at the time of delivery is what must be documented. This is necessary to differentiate your customization steps from those of “Limited Self Adjustment”Unfortunately, Medicare likley will not recognize what the laboratory did as sufficient even if they acted as your proxy, because it was not done at the time of delivery.

I recently sent an order to a lab with patient measurements. Their staff assembled the device from a kit to the measurements I provided. They then sent me the fully assembled device. Does this qualify the device as custom fit? If not, what must I do and document to qualify this device as custom fit? - WoodsideDR

Includes fitting and adjustment or custom fit by someone with expertise is a pre fabricated device which has been altered significantly so that this device is unique for one single patient to use. The difference between these two is that the narrative for includes fitting and adjustment has no prefabricated off the shelf version (e.g. L1971). The second one which has “ custom fit by someone with expertise” does have an off the shelf (L4386 vs. L4387). For more information see the AFO LCD policy. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33686

What exactly does includes fitting and adjustment or custom fit by someone with expertise mean. Aren’t they the same? I am confused by both of these HCPCS codes and how they differ.

I am confused about the two custom fit codes vs ots Pleae explain

Agreed it is not considered debridedment if you bill CPT 15004/15005 per AMA are “Surgical preparation or creation of recipient site by excision of open wounds…” It would not be adviseable to say debridement that would fall most likely as CPT 11042, plus debridement should not be billed for the same date for the same site of a skin graft.

No. The definition of CPT code 15004/5: surgical preparation or creation of recipient site by EXCISION of open wounds, burn, eschar or scar…… The area but be excised and not just debrided and the documentation must say so.

If I debrided an ulceration in preparation for the application of a skin graft, would it be appropriate to use CPT code 15004/5?

Definitely check insurance payer websites, the best answer is use specified diagnoses whenever possible and stay away from symptoms R diagnoses or unspecified coding.