Question :
Our facility was audited for using code L-5930 (addition, tadalafil endoskeletal system, ask high-activity knee control frame) because we submitted our claim with the K3 modifier instead of the K4. When Ottobock provided us the coding for its microprocessor knee, online it provided us the L-5930 code but did not let us know that this code required the K4 modifier. Recently, we have been working with an Ossur Rheo Knee, and again we received the L-5930 code and no information regarding the need for the K4 modifier. Is there a reason these companies are not informing providers that there are modifiers with these codes? Shouldn’t there be some responsibility on the vendors’ behalf for not providing the correct information?

Answer :
One of the most basic and important documents that your billing department should have in its possession is a copy of the Local Coverage Determination (LCD) for Lower Limb Prosthesis. This document, available from your Medicare Administrative Contractor (MAC), lists all relevant coding and functional-level restrictions, and it should be fully integrated into your billing practices. If you review it, you will see that effective January 1, 2006, Medicare implemented a K4 functional-level requirement for L-5930. Based on this, the Össur coding suggestions include a footnote instructing practitioners to check their local Medicare guidelines before using this code.

Question :
I have written to you in the past regarding denials for shoulder-elbow orthoses. I have refiled all claims with the correct codes that you provided me with, and I am happy to say all my claims have been paid. I am now receiving similar denials for L-3966 (shoulder-elbow orthosis, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment) and L-3969 (shoulder-elbow orthosis, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke-type suspension support, prefabricated, includes fitting and adjustment). Have these codes been discontinued?

Answer :
As of January 1, 2012, L-3966 has been crosswalked to E-2628 (wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining); L-3968 (shoulder-elbow orthosis, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment) has been crosswalked to E-2629 (wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support [friction dampening to proximal and distal joints]); and L-3969 has been crosswalked to E-2630 (wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke-type suspension support). You can find this information at www.oandp.com/link/149

Question :
Medicare denied an appeal I submitted. The original denial stated that the device was not considered medically necessary. Can I resubmit my appeal and request that Medicare look at it again, or do I have to accept the decision as final?

Answer :
If you filed an appeal to Medicare and you received a denial you can take the next step in the appeal process, which is called the reconsideration process. You will need to download a reconsideration form, which can be accessed at www.oandp.com/link/150. To read information on all levels of the appeals process, visit www.oandp.com/link/151