I was just reading over this issue this morning. The code you would use would be Q4050 for Medicare and other insurances you would use an A code. Sometimes insurances will cover these but it's based on medical necessity. Your best bet would be to contact the patient's insurance to see if they would pay. Here is some information from an article I was reading from the Orthopaedic Coders Pink Sheet this morning. It's long, but I think it might help you.
Check payersâ waterproof cast policy before charging patients
That harmless sign hanging in your office that reads âAsk about waterproof cast padding for an extra $20,â may be a violation of your payer contracts.
Not only is waterproof cast padding covered by Medicare, but many private payers will also foot the bill with the right documentation. That means if you inform patients they will have to pay out of pocket because waterproof cast padding is not covered, you could be risking an audit, or worse.
In the Nov. 1, 2000 , Federal Register, CMS states that Procel, a type of waterproof cast padding, is separately billable with documented medical necessity. Additionally, the agency directs you to report code Q4050 for the materials.
On the private payer side, if your clinic bills a patient for waterproof cast padding and the product is reimbursable with a payer you contract with, the clinic could be forced to pay civil money penalties, says Lester Perling, a partner at Broad and Cassel law offices.
To avoid violations, itâs important to consult your payers to determine if they cover waterproof cast padding, and if so, under what code. (Q4050, 99070 or one of the A-codes)
Still, some practices are billing patients the full cost, or not offering the product at all, while others have begun billing but are tackling the task with a risky approach.
Guess and bill can be costly
A Utah medical clinic just recently started billing carriers for waterproof casting materials, said a coder at the office. But instead of consulting carriers, the clinic is just billing them to determine who covers the service via trial and error.
âWe werenât sure how we were going to go about it all,â the coder says. âI think theyâre just having us straight bill their insurance.â
What this coder means, is that patients arenât being asked to fill out Advance Beneficiary Notices or waivers prior to receiving the service, a potentially costly mistake, Perling says.
âIâm never comfortable with âLetâs just bill it and see if they pay it or not,ââ Perling says.
The Utah clinic could bill the patients if the claim is rejected due to statutory noncoverage. But if the carrier decides the casting is not medically necessary, the clinic may end up eating the cost since there wasnât an ABN or waiver.
âIf theyâre denied because theyâre not medically necessary, then no, you canât bill the patients,â Perling says. âIf itâs one of those situations where itâs still grayâŠthen they should definitely get an ABN at the time the service is rendered.â
Trial and error billing can also lead to another unfortunate situation: over payments, Perling says. If the carrier does not realize it shouldnât be reimbursing for waterproof cast padding and does so anyway, it could ask for repayment months or years later.
Meeting the medical necessity burden
To ensure the claim is reimbursed, Medicare and private payers require documentation of medical necessity. Often, coders find the medical necessity standard difficult to meet.
âThere are situations where it is medically necessary but theyâre few and far between,â says Kristi Stumpf, medical compliance specialist for Proliance Orthopedics and Sports Medicine in Bellevue , Wash. âItâs almost always a convenience issue.â
Proving medical necessity could be the most important step in gaining reimbursement. Medicare states Q4050 is carrier priced, but only Montana Medicare published a definite fee schedule. Reimbursement ranges from $30.79 for padding for short-arm fiberglass casts to $61.08 for padding for long-leg fiberglass casts.
Other providers, like Cigna, require an invoice for casting supplies to determine reimbursement.
Though diabetes, thin skin and ulcers are the most obvious diagnoses that would qualify for medical necessity, coders said, a variety of other conditions could make waterproof casting payable.
Patients who act as caregivers for significant others or children and frequently get their hands wet can qualify, says Margie Scalley Vaught, CPC, CCS-P, MCS-P, ACS-EM, ACS-OR, an independent coding specialist in Chehalis, Wash., in a recent audio conference sponsored by OCPS.
Military personnel and other professionals who would be able to return to work sooner with a waterproofed cast are also viable candidates, Vaught says. And while flu season is still months away, CMSâs constant reminders to wash your hands are a perfect explanation for waterproof necessity, Vaught adds.
The most important element to ensure reimbursement is documentation, both to prove medical necessity and to prove the carrier covers the service.
Expert Tips: Check out Montana
Contact your carrier: âThe first thing I would do would be to advise the client to attempt to determine if thereâs a local coverage determination on this type of service,â Perling says. âWrite a letter to the carrier and say do you have any guidelines on billing for this particular code.â
Look for national coverage decisions from payers. Some private payers include requirements on their Web sites, such as including an invoice for the padding.
Montana Medicare recommends you include a description of supplies in Item 19 of the CMS 1500 form, its Web site states. For example, âGortex used for long-leg cast.â
Document medical necessity using an ICD-9 code if possible.
Have patients fill out an ABN or waiver before applying waterproof casting.âS. Murray
I hope this helps
Christy Brown, CPC
Appalachian Orthopedic Associates P.C
Johnson City, TN