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Wiki DME denials - Please help

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miedemarebecca@gmail.com

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Hello, I am currently coding for a podiatry group. We are experiencing high denial volumes when it comes to our DME being billed. In particular L3000, L3260, and more. Insurance companies range from commercial insurances to Medicare advantage plans. I am billing these with laterality. The denial reason states; " this should be billed with the appropriate code for the services reported" or " procedure dx code mismatch." This to me indicates perhaps I am not reading the LCD correctly, or we are missing something. Please assist by adding any further info you may have on this.
 
Medicare nor Medicare Advantage plans cover custom orthotics, this is likely why you are getting denials. The LCD you mention states that an orthotic is covered when attached to a covered brace...which rarely if ever is the case. In addition, many commercial payers do not cover them either. For Medicare and Medicare Advantage plans, these should be cash pay, no ABN is required as they are not covered. For the commercial plans, patients should check coverage first, if they agree to casting, they should sign an agreement that if their insurance does not pay they are liable for full balance. In addition, collect a deposit of at least half up front for all payer types.
 
podcoder70 said:
Medicare nor Medicare Advantage plans cover custom orthotics, this is likely why you are getting denials. The LCD you mention states that an orthotic is covered when attached to a covered brace...which rarely if ever is the case. In addition, many commercial payers do not cover them either. For Medicare and Medicare Advantage plans, these should be cash pay, no ABN is required as they are not covered. For the commercial plans, patients should check coverage first, if they agree to casting, they should sign an agreement that if their insurance does not pay they are liable for full balance. In addition, collect a deposit of at least half up front for all payer types.
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wow thank you! this is very helpful info.
 
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