Wiki DME code - L3000

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01503628

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Hi All....

I am receiving denials from Medicare DME for the CPT L3000 as CO-16( Claim service lack for information) these claim also contains a remark code M124 (Missing indication of whether the patient owns the equipment that requires the part or supply) from Feb 2022 and we are using KX modifier for all claims with RT/LT Modifier.

Please somebody help me whether need to follow any other guidelines for Medicare claims on L3000.

Thanks in advance!!
 
Hello,

I started seeing denials like this from Noridian Medicare. They are cracking down the the usage of KX. To append KX you are attesting that the insert is an integral part of the leg brace. What they are looking for in Box 19, is the HCPCS code of the leg brace and the date of purchase. I confirmed with Noridian DME, that yes, we would need to reach out to the provider/supplier of the leg brace to obtain this information.

Hope that helps!
 
01503628 said:
Hi All....

I am receiving denials from Medicare DME for the CPT L3000 as CO-16( Claim service lack for information) these claim also contains a remark code M124 (Missing indication of whether the patient owns the equipment that requires the part or supply) from Feb 2022 and we are using KX modifier for all claims with RT/LT Modifier.

Please somebody help me whether need to follow any other guidelines for Medicare claims on L3000.

Thanks in advance!!
Click to expand...
Please see my response :)
 
We have also seen denials for this and other shoe insert codes. Our provider was trying to bill these with a boot, but per our local Medicare DME rep, they are not reimbursable with boots, only braces. Just an FYI. :)
 
Hi Lexi,

Thank you so much for keeping me in the loop! We are in difference DME Jurisdiction D, however, we can get L3260/L3260 paid for patients who have diabetes, for the prevention or treatment of diabetic foot ulcers. If that this is the case, then I append a KX modifier. The L4360/L4361, I've had a tougher time with. Sometime is bumps up against frequency limits and other times it's a medical necessity denial. Due to the denial of frequency limits, we have started requesting an ABN.

I'd love to know your thoughts :)
 
Heatherc7 said:
Hi Lexi,

Thank you so much for keeping me in the loop! We are in difference DME Jurisdiction D, however, we can get L3260/L3260 paid for patients who have diabetes, for the prevention or treatment of diabetic foot ulcers. If that this is the case, then I append a KX modifier. The L4360/L4361, I've had a tougher time with. Sometime is bumps up against frequency limits and other times it's a medical necessity denial. Due to the denial of frequency limits, we have started requesting an ABN.

I'd love to know your thoughts :)
Click to expand...
Hi Heather! So with the frequency limits, it's likely a same/similar denial meaning the patient received the same or similar DME within the last 5 years. Our providers typically get ABNs for every brace now due to their specialty (Orthopedics) and that they are usually the one providing the first and second braces. If the patient is receiving a same/similar brace, but it is for a separate medical condition, you can usually submit a redetermination to have it covered. One instance is if a patient received a knee brace for pain/instability, but later fell and fractured her knee and received another knee brace, the second may be covered with supporting documentation. There is a look up tool on the CGS website (DME jurisdiction C) that we use to confirm same/similar. It's not patient specific, and allows you to type in the HCPCS code and search for all other DME that CMS considers same/similar to that code.

The medical necessity denial could be for the diagnosis. Have you looked up the LCD/Article for the DME? The Article will list the diagnosis codes that support med nec.
 
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