Billing for O&P devices and care is complicated. When you have questions, ambulance treatment count on “Got FAQs?” to help keep your claims on track. This month’s column addresses your questions about PECOS claims rejection, see O&P modifiers, there and services for SNF patients.

Question
Has the Centers for Medicare & Medicaid Services (CMS) posted or started giving providers notice when claims rejection begins if an ordering/referring provider does not have a record in the Provider Enrollment, Chain and Ownership System (PECOS)?

Answer
According to a CMS press release, “At this time CMS has not turned on the automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS. CMS is working to resolve backlog and other systems issues and will provide ample advance notice to the provider and beneficiary communities before CMS begins any such automatic denials.” For more information regarding enrollment, common questions, and using PECOS, visit www.oandp.com/link/107 or www.oandp.com/link/108
Question
I am a new billing manager for a Region C O&P practice. I have received denials for incorrect modifiers. Can you provide me with any resources I can use to find the correct modifiers and their descriptions for O&P?

Answer
The Cigna Government Services (CGS) supplier manual, chapter 16, provides information on all durable medical equipment (DME) and O&P modifiers, with complete descriptions for each, at www.oandp.com/link/110. You may also use Medicare’s Modifier Tool on the Region C website by going to www.oandp.com/link/111

Question
In recent months, we have received denials for prosthetic devices we provided to patients residing in a skilled nursing facility (SNF). I was under the impression that a prosthetic device was covered when provided to such patients. Did Medicare recently change their guidelines?

Answer
On August 2, Medicare issued the following statement: “Since Monday, April 4, our claims processing system has been erroneously denying claims for certain custom prosthetic devices. CMS is issuing instructions to correct this processing error, but the correction will not be implemented until Sunday, January 1, 2012. In the interim, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) will reprocess any claims for custom prosthetic devices (identified by the “L” series of the Healthcare Common Procedure Coding System [HCPCS] codes) that were inappropriately denied when such claims are brought to their attention.” Medicare guidelines state that Part B payment can be made for prosthetics, orthotics, and supplies when they are furnished to a beneficiary who is in a non-covered, Part A stay at a hospital or SNF. An exception to this policy is when certain customized prosthetic devices are furnished to beneficiaries residing in a covered Part A SNF stay, as these items were carved out of the SNF Consolidated Billing provision by the Balanced Budget Refinement Act of 1999 (BBRA, PL 106–113, Appendix F, Section 103). To read the press release, visit www.oandp.com/link/112