Answers from AOPA Reimbursement and Compliance Experts

Virginia Torsch is the assistant director of reimbursement services for the American Orthotic & Prosthetic Association (AOPA).

AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals. Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession.

Q: I am trying to find a particular L code on my DMERC's fee schedule, and it is not listed. Does this mean the code is not covered by Medicare?

A: Not necessarily. While it is true that CMS and the DMERCs do not usually list the codes not covered by Medicare—for example, codes for orthopedic footwear—on their fee schedules, the lack of a code does not automatically mean the item is not covered. In some instances, the DMERC fee schedule does not list covered codes simply because a reimbursement amount has not been set. And even the CMS DMEPOS master fee schedule list is inconsistent about how they list codes with no fees.

Sometimes CMS will list the fee as $00.00; other times, CMS will not list the code at all. For example, CMS did not include the following new 2006 codes on the DMPEOS fee schedule:

• L2034 (KAFO, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated)
• L2387 (Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint)
• L7600 (Prosthetic donning sleeve, any material, each)

However, CMS did include most of the other new 2006 L codes, even though they do not yet have fees, and just assigned these codes fees of $00.00. The DMERC fee schedules, on the other hand, left off all of the new 2006 codes and some of the codes that were new in 2005 that do not yet have a fee assigned to them.

So, just because a code is not on the DMERC fee schedule or is missing from the CMS DMEPOS fee schedule, do not assume it is an invalid code or a code that is not covered by Medicare.

Q: Well then, how do I find out if the code is still valid?

A: You can check the code on the master Healthcare Common Procedure System (HCPCS) list, which can be accessed at the following Web site: www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp.

If you use this list, you must pay attention to the column on the far right that tells you whether this code has recently been deleted or added. The column will have a D for deleted or an A for added and a date when the action took place.

AOPA has several coding products containing an updated list of all HCPCS orthotic, prosthetic and shoe codes.

• The 2006 AOPA Quick Coder™ contains a listing of the orthotic, prosthetic and shoe codes on laminated cards for easy reference and durability.
• The 2006 AOPA Illustrated Guide™ is a manual providing illustrations and descriptions of medical codes in use for orthotics, prosthetics and shoes.
• The 2006 AOPA CodingPro™ software, similar to the Illustrated Guide, includes official Medicare descriptors and an AOPA interpretation of each orthotic, prosthetic and shoe code.

In addition, the Coding Pro operates with the functionality of a database, enabling you to import your own fee schedules, generate physician prescriptions and other supporting documents for your claims submissions, print them and even save them in Microsoft Word™. You can obtain more information about these products on www.AOPAnet.org. And, of course, AOPA members can call AOPA staff experts to verify codes.

Q: If an L code is listed on the CMS DMEPOS fee schedule with a $00.00 fee, how do I get paid for this code?

A: If the code is covered by Medicare and does not yet have a reimbursement amount set for it, CMS and your DMERC will consider this code an IC code—paid on individual consideration.

This means you set your own charge for this code, but you must be prepared to justify why are you are charging that amount. Keep copies of the invoices for the item if prefabricated, or for the material you used, and document the amount of time you spent fabricating or fitting the device or component.

Q: Why does it take so long for CMS to set a fee for a new code? And why do they frequently end up setting a fee that is totally inadequate for the actual cost of the device or component?

A: If the new code has not been crosswalked from an old code or a temporary code that already had a fee, then CMS uses a "gap filling" methodology to establish a fee for that code.

This complex methodology entails taking the current price for a device or component, deflating it back to the price it would have been in the base years of 1986-87 and then increasing that price by the congressionally set price increase for each year up to the current year.

Sound complicated? It certainly is. Additionally, the methodology depends on a number of variables that sometimes result in lower reimbursement amounts than the actual cost of the device or component.

The variables include:

• Not considering the full range of pricing for a device—for example, in the past CMS has only considered prices for some orthoses at the lower range of the spectrum of devices;
• Using wholesale prices as the start point instead of retail prices;
• Not considering updates in new technology; or
• Using pricing for devices that are not representative of the new code.

AOPA is working with CMS to address these problems in an effort to get adequate reimbursement fees set for new codes in a timely manner. In the meantime, if you have questions about fees for new codes, you can contact me by phone at (571) 431-0876, ext. 212, or by e-mail at vtorsch@AOPAnet.org.