Billing for O&P devices and care is complicated. When you have questions, rx count on “Got FAQs?” to help keep your claims on track. This month’s column addresses your questions about billing for L-2755, Medicare as a secondary payer, and using the Medicare Pricing, Data Analysis, and Coding (PDAC) website.

Question
What is needed to bill L-2755 (addition to lower-extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only)? We are in Region C, and I just received retractions from Medicare on three patients who received L-2755 in 2009. In reviewing the Local Coverage Determinations (LCD) on Region C’s website, we have not found the necessary information.

Answer
You did not state the specific reason Medicare is retracting the money paid for the L-2755. This was a valid code in 2009, and according the LCD, “L-Coded additions to AFOs and KAFOs (L-2180–L-2550, L-2750–L-2768, and L-2780–L-2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.” If your claim did not include a KX modifier, this may have been the reason for the retraction, as there was a revision effective June 1, 2009, that requires the inclusion of the KX modifier when billing for this L-Code.

Question
Will Medicare pay for a C-Leg® as a secondary payer when the primary payer denies payment due to non-coverage? Our patient is a Medicare beneficiary who has had a transfemoral amputation resulting from an on-the-job injury. Our state’s Labor and Industries (L&I) department, which administers worker’s compensation insurance, does not cover the C-Leg components but will cover all other Healthcare Common Procedure Coding System (HCPCS) codes related to the amputation. If I was to bill L&I and they pay for all but the C-Leg codes, can I bill Medicare as a secondary payer for reimbursement of the L-5856, L-5828, etc.?

Answer
If a beneficiary is covered under any of the following insurance plans, then Medicare would be considered a secondary payer: (1) Group health insurance (employer has 20 or more employees). This insurance is provided by an employer to a policyholder who is actively working and is governed by specific laws, including the Tax Equity and Fiscal Responsibility Act (TEFRA), Deficit Reduction Act (DEFRA), Omnibus Budget Reconciliation Act (OBRA), Consolidated Omnibus Budget Reconciliation Act (COBRA), and End Stage Renal Disease (ESRD) program. (2) Automobile or liability insurance. This insurance is applicable in cases where an accident has occurred whether it is a car accident, a fall, or medical malpractice. (3) Worker’s compensation, which covers injuries on the job. In the situation you described, worker’s compensation is responsible for the claim first. You can find complete information on Medicare Secondary Payer (MSP) at www.oandp.com/link/103.

Question
I have tried using the Medicare Pricing, Data Analysis, and Coding (PDAC) website and was wondering if there is someone I can contact about how to use this site.
Answer
On its website, www.dmepdac.com, the PDAC supplies a web-based application that provides HCPCS coding assistance and national fee-schedule information. The application is called the Durable Medical Equipment Coding System (DMECS). It is designed to help people quickly search for HCPCS code information, modifi er descriptions, fee-schedule information, and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). You may call the PDAC contact center from 8:30 a.m. to 4 p.m. Central time at 877.735.1326. To access the complete user guide, visit www.oandp.com/link/104.