O&P ACT Question and Answers - February 20, 2018

Questions Received Prior to ACT

Q1. How will the new legislation as listed below effect the need for device specific physician documentation? Is this change effective immediately?

SEC. 50402. ORTHOTIST'S AND PROSTHETIST'S CLINICAL NOTES AS PART OF THE PATIENT'S MEDICAL RECORD. 13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:

''(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. - For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).

A1. As contractors, we require CMS instructions before implementing any new legislation. Watch our listservs for any announcements.

Q2. A supplier has been running into same/similar Reasonable Useful Lifetime (RUL) issues (five-year replacement) for a few patients lately. From what is read and indicated within DME on demand, suppliers are to use a modifier stating that an Advance Beneficiary Notice of Noncoverage (ABN) has been completed and is on file; however, the KX modifier is not. Are suppliers to append the KX modifier upon appeal? Are suppliers not to bill initially with both modifiers? Suppliers want Medicare to know that yes, we have a signed ABN advising that this could be a payment issue but should also be aware that all medical documentation is on file to substantiate medical necessity.

For example: Patient was provided an Ankle-Foot Orthosis (AFO) in August 2017. He/she is a lower extremity paraplegic, who has worked hard in physical therapy and increased his mobility enough to prove medical need for a Knee-Ankle-Foot Orthosis (KAFO), added diagnosis code per doctor's clinical documentation that knee instabilities are now present. AFO and KAFO base code are on the same list. How does a supplier appropriately submit this for claim payment review?
A2. Multiple factors apply for this response: 1) the KX modifier indicates all coverage criteria are met, 2) the GA modifier indicates that the beneficiary has been informed of the reasons Medicare will not pay, 3) that means the KX and GA would not be used together and 4) a change in medical condition may warrant provision of a same/similar item.

When suppliers are dispensing an item that does meet the Local Coverage Determination (LCD) and Policy Article (PA) coverage requirements but is expected to deny as same or similar due to another item being dispensed to the beneficiary within the RUL, suppliers are advised to administer an ABN prior to delivery and submit the claim with the GA modifier and all other policy-specific modifiers (minus the KX modifier). Upon denial, the supplier may submit a Written Redetermination with all applicable documentation. If the written redetermination team feels replacement of that item was warranted within the RUL, the KX modifier will be appended at that time and payment will be made. If it is determined that payment for the replacement was not warranted, the claim will be denied as patient responsibility assuming a valid ABN was obtained.

Questions During the ACT

Q1. We have been billing the HCPCS L5962 prosthetic cover with a GY modifier and it has been getting paid. We don't believe Medicare should be paying for this item and are not sure how to bill it to get a denial.
A1. Per the Lower Limb Prosthetic (LLP) LCD and PA, this is not a "noncovered" item. Per Appropriate Coding and Billing of Lower Limb Prosthetic Covers and Covering Systems, the HCPCS L5962 may be covered if the beneficiary meets the medical necessity requirements for reimbursement. Therefore, if documentation does not exist to support the medical necessity of the HCPCS L5962, suppliers are advised to administer an ABN prior to delivery and submit their claim with a GA modifier.

Q2. Is there any way to communicate to secondary insurance that the GY modifier is used to indicate that an item is statutorily non-covered under the Medicare program requirements only?
A2. This is not a Medicare issue. Noridian recommends suppliers contact individual private insurance companies for direction on this matter.

Q3. Has there been any change in RUL or is it still five years?
A3. Under the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) program, RUL is considered to be five years unless a specific policy indicates otherwise. Overall, the five-year RUL applies to orthotics and prosthetics, however the knee orthosis policy is unique for this rule. RUL is considered anywhere from one to three years depending on the specific HCPCS for knee orthosis which will be defined in the Knee Orthoses LCD (L33318).

Q4. Does Noridian have any webinars pertaining specifically to physician required documentation including examples of compliant documentation?
A4. As a DME Medicare Administrative Contractor (MAC), we are primarily tasked with supplier education; however, we encourage the supplier community to invite their referral sources to an electronic visit that will allow both parties to hear the Medicare requirements together. We are also increasing our partnerships with Part B contractors and providing more collaborative education for physicians concerning the ordering of DMEPOS items.

Q5. How much detail is required in the physician's notes?
A5. Physician records must tell the patient's story as Noridian's clinical reviewers do not have the opportunity to meet and evaluate the patient themselves. It requires more than a diagnosis; a picture must be painted. Two patients may have the same condition, but differing needs. An e-visit can be very beneficial in defining these requirements.


  • New Medicare Card Project
    • Card issuance begins April 1, 2018
    • CMS website contains a general mailing schedule
    • Transition period is April 1, 2018 to December 31, 2019
    • During transition claims may be submitted with either Health Insurance Card Number (HICN) or Medicare Beneficiary Identifier (MBI)
    • Beginning October 1, 2018 remittance advice will contain both HICN and MBI
    • January 1, 2020 claims can only be submitted with MBI
      • Appeals will accept HICN for DOS in the transition period
  • Electronic Supplier Visit (E-Visit)
    • Free consultation with Provider Outreach and Education subject matter expert
    • Clinical Reviewer may be in attendance
    • Offers education specific to what is important to your business
      • Encourage inclusion of referral sources
  • Target Probe & Educate (TPE)
    • Policy categories are selected based on numerous considerations
      • Claims posing the highest financial risk
      • High nation errors
      • High claim error rates
      • Billing practices of a supplier that vary significantly from their peers
      • Data analysis
    • Suppliers are selected within that policy category
    • Selected suppliers receive a letter
    • 20-40 claims are selected per round
      • Read request letters carefully
      • Provide what is requested
    • Up to 3 rounds may occur
    • Phone and E-visit education take place
    • Suppliers notified when removed due to successful completion
  • Monday Live Chat
    • Occurs every Monday at 2 p.m. CT for 30 minutes
    • Ask the education staff the questions on your mind
  • Noridian is now on Facebook
    • Please like and follow us
    • CERT reduction Initiative
    • Mini webinars targeting specific policy groups
    • Intended to assist in lowering CERT errors
    • Assist suppliers in understanding the overall error reasons by policy
    • Repair and replacement education
    • Webinars hosted regularly
    • O& P specific scheduled for May 22, 2018
    • Level 200 Webinars
    • Excellent opportunities to hear claim specific scenarios
    • Suppliers are encouraged to submit examples (No PHI)
    • Examples can be faxed to Noridian

Resources and Reminders

Next Call

  • February 9, 2018 DME ACT


Last Updated Feb 05, 2020