Reprocess Customized Prosthetic Device Claims

Since April 4, the Medicare claims processing system has been erroneously denying claims for certain custom prosthetic devices. Durable medical equipment Medicare administrative contractors (DME MACs) have been instructed to reprocess any claims for custom prosthetic devices (identified by the “L” series of HCPCS Level II codes) that were inappropriately denied. If suppliers want to be paid this year, however, they’ll have to do the leg work.

Contractors are not able to automatically adjust these claims as yet. Suppliers must bring such claims to the attention of their DME MAC for reprocessing until contractors are able to correct this processing error. According to the Centers for Medicare & Medicaid Services (CMS), that won’t be until Jan. 1, 2012.

The problem stems from the fact that Medicare Part B payment can be made for items of prosthetics, orthotics, and supplies when they are furnished to a patient who is in a non-covered Part A stay at a hospital or skilled nursing facility (SNF). If these items are furnished to patients residing in a covered Part A hospital or SNF stay, under the Inpatient Prospective Payment System (IPPS) or SNF consolidated billing (CB) payment rules, the items would be bundled into the global Part A payment for the covered stay itself. An exception to this policy is when certain customized prosthetic devices are furnished to patients residing in a covered Part A SNF stay, as these items were carved out of the SNF CB provision by the Balanced Budget Refinement Act of 1999 (BBRA, PL 106-113, Appendix F, section 103).

Source: CMS Provider Partnership Email Archive, July 26

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