Q4: KO Coding and Compliance

Question 1

Jursidictions in Medicare

Answer 1

Four Total (A, B, C, D)

O&P - Part B (unless hospital patient)

Question 2

DME Claims are outsourced to…

Answer 2

MAC - Medicare Administrative Contracter

Question 3

Typical Percent covered under Medicare

Answer 3

80% (remaining will be secondary or “cash”)

Question 4

Qualifications for Medicare

Answer 4

1. over 65
2. Disabled
3. End stage renal disease
4. ALS

Question 5

PDAC

Pricing, Data, Analysis, & Coding

Answer 5

tasked with verifying codes for orthoses & prostheses
(do devices meet the code description)

Question 6

Competitive Bidding Program

Answer 6

Certain OTS device codes (spine and knee) can only be provided by suppliers contracted with the program

created to reduce tax payer money and reduce fraud

Question 7

Prior Authorization

Answer 7

Used for higher risk codes (L1832/1833/1851)

Supplier must submit docs to medicare and recieve approval before delivery

takes between 3-5 days

Question 8

Physician’s Orders

Answer 8

All devices need a Standard Written Order

Some also need a written order priot to delivery

Doc must chart in record pt’s need for Ox with objective diagnosis

Question 9

KO Categories

OTS (Prefab)

Answer 9

described as minimal self adjustment for fitting

Question 10

KO Categories

Custom Fit

Answer 10

documentation must include that device requires adjustments from someone with clinical expertise

Question 11

KO Categories

Custom Fab

Answer 11

covered when documentation states characteristic that deems it is required
* deformity
* abnormal size/stature
* minimal muscle mass for suspension

Question 12

KO Coverage Criteria

Answer 12

Typically must…
* be ambulatory
* have deformity
* require stability
* KO must have ridity (or hinges)

Soft sleeves not covered

Question 13

HCPCS and LCD relationship

Answer 13

HCPCS codes will require specific coverage criteria from LCD

• HCPCS - healthcare common procedure coding system
• LCD - local coverage determinant