AOPA Answers
Bilateral Billing Answers to your questions regarding bilateral componentry
AOPA
receives hundreds of queries from readers and members who have questions about some aspect of the O&P industry. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@strattonpublishing.com.
Q.
Is it true that a bilateral amputee can have any prosthetic componentry he or she wants and is not subject to a functional level assessment and the K-levels?
A.
The Medicare Lower Limb Prosthetic Policy states the following: “It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.” While this statement recognizes that there may be individual circumstances in which a bilateral amputee may have a clinical need for componentry that exceeds his or her functional level assessment, it does not mean that bilateral amputees have no limits on the type of prostheses for which Medicare will pay. Bilateral amputees must undergo a functional level assessment and be assigned a functional level (K-level modifier); in most cases, they will only qualify for prosthetic components within their functional level classification. If there is a specific clinical need for prosthetic components that exceed the patient’s functional level classification, the need must be welldocumented and supported by information in the patient’s medical record.
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O&P Almanac JULY 2013
Q. A.
How many claims may RACs audit?
The Centers for Medicare and Medicaid Services has modified the number of Additional Documentation Requests (ADRs) that a Recovery Audit Contractor (RAC) may make for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers. The number of ADRs a RAC may make per 45 days is limited to 10 percent of all claims submitted under a single Tax ID for the previous calendar year, divided by eight. However, for suppliers that are classified by the following taxonomy codes, there is a limit of no more than 10 ADR requests per 45 days: • 51—Medical Supply Company with Orthotist • 52—Medical Supply Company with Prosthetist • 53—Medical Supply Company with Orthotist-Prosthetist • 55—Individual Certified Orthotist • 56—Individual Certified Prosthetist • 57—Individual Certified Prosthetist-Orthotist. Therefore, if you are classified as any of the above, the maximum amount of claims that could be audited by the RACs in a 45-day span is 10. a