AOPA TOP TEN SERIES Top Ten Myths in O&P Billing 2009 AOPA National Assembly Seattle, Washington

Top Ten Myths in O&P Billing MYTH: Bilateral amputees are not subject to functional level restrictions FACT: Bilateral amputees require a functional level assessment Medicare policy states that bilateral amputees are not strictly bound by functional level but medical necessity must still be established

Top Ten Myths in O&P Billing MYTH: Medicare payment rules do not apply to non-assigned claims FACT: The same payment rules apply to non-assigned claims as assigned claims. Providers have the same level of liability on non-assigned claims

Top Ten Myths in O&P Billing MYTH: Medicare will not pay for a diabetic shoe that is worn over a prosthesis FACT: Medicare covers a PAIR of diabetic shoes for patients who meet coverage criteria. One of the coverage criteria is a history of amputation of a part of or all of either foot

Top Ten Myths in O&P Billing MYTH: Nobody pays for unlisted procedure codes FACT: In 2007, Medicare reimbursements for unlisted O&P procedure codes exceeded $1.5 million.

Top Ten Myths in O&P Billing MYTH: Patients cannot have a prosthesis and a power wheelchair/scooter at the same time FACT: Medical policy for power wheelchairs no longer requires the patient to be non-ambulatory. Patient should be evaluated to determine the medical nee for the prosthesis only

Top Ten Myths in O&P Billing MYTH: Medicare does not cover liners on preparatory prostheses FACT: The Lower Limb Prosthesis Medical Policy was revised several years ago to remove this restriction

Top Ten Myths in O&P Billing MYTH: The KX modifier guarantees claim payment FACT: The KX modifier is used to tell Medicare that required documentation to support the medical necessity of you claim is in your files. It is not a guarantee of payment

Top Ten Myths in O&P Billing MYTH: Medicare never pays for orthopedic shoes FACT: Medicare will pay for both custom and off the shelf orthopedic shoes as long as they are an integral part of a brace

Top Ten Myths in O&P Billing MYTH: You may not deliver an O&P device without a detailed written order FACT: You may deliver an O&P item based on a verbal or non detailed written order. You must have a detailed written order in your files before you may submit your Medicare claim

Top Ten Myths in O&P Billing MYTH: All Prostheses are exempt from SNF PPS and may be billed directly tothe DME MAC FACT: Only codes that are specifically listed as exempt may be billed to the DME MAC during a Medicare Part A SNF stay. All other codes must be billed to the SNF.