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DME - Modifier Help, Please

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PippiT:
Can L4361 & L1971 be billed together? I am not finding anything in the NCCI Edits and google leads me to believe they possibly cannot, but I cannot find a straightforward answer.

Originally the claim denied L4361, NU, RT as being inclusive with L1971, NU, RT. I sent in an appeal with notes backing up that they are two separate items. It was denied but that a corrected claim with an appropriate modifier could be submitted.

I submitted a corrected claim with the 59 modifier on the L4361, NU, RT and it denied again that it is inclusive of the L1971. I'm at a loss. I looked back and we have never billed these two codes together. So I began searching if they can be billed together but I am not finding anything.

Any input/insight? Thank you.

Michele:
Are the items for the same leg/foot?  If they are for separate limbs then they are looking for the RT/LT modifier.  If they are for the same limb, I'm not sure.   By description they do seem to be inclusive but since they reviewed and stated appropriate modifier could be submitted it sounds as if they agree that they could be allowed separately.  I found a list of DME modifiers, but I'm not seeing one for this situation.  Maybe you will spot it:

 https://www.cgsmedicare.com/medicare_dynamic/modifiers_dme/results.asp

rballinger1:
We do a lot of lower extremity DME.  Is it possible the HCPCS code for the ankle device are incorrect? The walking boot and the ankle brace are basically the same item, one is a lot shorter than the other.  Could the provider notated the one code in error?  It would be rare for a patient to be dispensed these two items at the same time for different extremities as well, but would be covered if the diagnosis supported LT and RT.  I would review with the provider and confirm the correct HCPC codes were provided originally.  Call the payor and ask if the reimbursement policy for these two items are available for review on their website.  You will find these codes listed on most payors websites under "Reimbursement Policies".  The HCPCS code for both devices are listed under the AFO coverage and limitations for DME supplies.  DMERC shows that both devices must have the KX modifier; however, the two items should not be issued at the same time for the same extremity.  Typically, we bill Medicare KX, NU. RT, GA modifier when reporting ankle brace or walking boot.


DMERC's Policy and Criteria for Coverage:
AFOs AND KAFOs MUST BE USED DURING AMBULATION
                                                                             (Ankle Brace)                                            (Walking Boot)
Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:
Require stabilization for medical reasons, and,

Have the potential to benefit functionally.
Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.

AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:

The beneficiary could not be fit with a prefabricated AFO; or,

The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

There is a need to control the knee, ankle or foot in more than one plane; or,

The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.
If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) 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.

Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are coded as L2999 and are covered for beneficiaries who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used for the treatment of contractures, regardless of any co-existing condition(s), are coded as E1810 and/or E1815 and are covered under the Durable Medical Equipment benefit (refer to the CODING GUIDELINES section in the LCD-related Policy Article).

Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture and coded as L2999 will be denied as incorrect coding.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are covered under the refill requirements.

GENERAL

A Detailed Written Order (DWO) (if applicable) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed DWO, the claim shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

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