Reimbursement Services

Reimbursement Services and Resources

The Reimbursement staff at Ottobock fields more than 4,160 calls and 19,760 emails from patients and practitioners annually. Many of these calls are requests for documentation to support reimbursement of prosthetic and orthotic products and therapies.

After we help a customer solve a challenge, we often create a tool that can help other people navigate the same challenge, for example to help you create proper documentation for billing and coding purposes.

Reimbursement News and Updates

New Documentation and Clinician Checklists for Upper Limb Orthoses

Noridian has created a Documentation Checklist and a Clinician Checklist for upper limb orthoses. The checklists were created to help suppliers and clinicians understand the requirements necessary for upper limb orthoses when providing and billing. Although there is not an Upper Limb Orthosis Local Coverage Determination (LCD) Guidance suppliers are reminded to still abide by the Standard Documentation Requirements for All Claims Submitted to DME MACs Local Coverage Article criteria when documenting medical necessity for their patients.

Resources:
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426

https://med.noridianmedicare.com/documents/2230715/26734435/Documentation+Checklist+-+Upper+Limb+Orthoses

https://med.noridianmedicare.com/documents/2230703/16619307/Clinician+Checklist+Upper+Limb+Orthoses

PDAC Verified: Prosthetics

Items Requiring Coding Verification Reviews

Many items require coding verification review by the PDAC contractor. As indicated in Local Coverage Determinations (LCDs) and related Policy Articles containing such HCPCS codes, claims will be denied if the products requiring coding verification review are not listed on the PDAC Product Classification List.

View the current list of HCPCS codes that require coding verification review, the applicable LCD or Advisory Article for each code, and the code requirement effective date (i.e., claims with dates of service on/after).

A full list of Durable Medical Equipment and applicable coding can be found on the PDAC Classification List.

Prior Authorization Webinar Resources

Noridian Lower Limb Prostheses (LLP): Physician and Prosthetist Records Webinar

The supplier's notes are only part of the whole medical record and are considered in the context of documentation made by the referring provider and other healthcare practitioners to provide additional details to demonstrate that the prosthetic arm or leg billed to Medicare was reasonable and necessary. In other words, the supplier's notes are expected to corroborate and provide details consistent with the physician/practitioner records. In the event of a conflict between the physician/practitioner notes and the supplier's record, the DME MAC would likely deny payment. Similarly, payment may not be provided solely based on the supplier’s documentation. Therefore, in the absence of physician/practitioner documentation, the DME MACs may deny payment for the prosthetic component. VIDEO

Noridian Prior Authorization: Lower Limb Prosthetics Webinar

As of December 1, 2020, prior authorization through Medicare is required for codes L5856, L5857, L5858, L5973, L5980, and L5987 in all states and territories. Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered. The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner. Prior authorization requirements are subject to the supplier’s region and guidelines. VIDEO

Noridian Orthotics Same or Similar Webinar

Claims for Orthotic braces with dates of service within the reasonable useful lifetime from the date of service of a previously paid same or similar Orthotic Brace (similar or identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.

Reasonable Useful Lifetime (RUL) is the period of time, after which Medicare payment can be made for replacement of DME that is lost, stolen, or irreparably damaged. Computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment. The RUL is used to determine how often it is reasonable to pay for the replacement of DME under the Medicare program and is not explicitly set forth as a minimum lifetime standard. When it comes to RUL, one must consider "irreparable damage" and "irreparable wear". Damage refers to unexpected events, such as loss or theft, and are covered under RUL. Wear is the deterioration sustained from day-to-day usage over time that cannot be traced to a specific event. Wear is not covered by Medicare and does not meet the requirement of RUL.

To replace a same or similar Orthotic brace before the useful lifetime has expired, there must be a documented reason why the current device no longer meets the patient’s functional needs. There are a few tips you can use when checking same or similar equipment. Noridian and CGS have developed the following Medicare resources:

• Noridian Same or Similar Chart
• CGS Same/Similar Code Lookup
• Lower Limb Prostheses Replacements

Suggested HCPCS Codes - U.S. only

Suggested L-Codes for Prosthetics:

• Prosthetics Suggested Coding

Suggested L-Codes for Orthotics:

• Orthotics Suggested Coding

FAQ