A client of mine called and told me about a "New Policy" that their office received in the mail not long ago, from Medicare, relating to new non-covered HCPCS Codes for DMEPOS and she specifically mentioned L3310. She stated that Medicare was paying for this code, with the medical justification and diagnosis, and that they are going to stop paying for the L3310.

Not seeing or reading anthing new about this, I actually called and spent quite a while on the telephone with Medicare Representatives today relating to specific reimbursement allowance for a specific LCode because I wanted specific detailed answers to my question relating to L3310 (shoe/heel lift). This code is not foreign to me, I just wanted to test the waters and see what kind of information I could gather from these sources, and what kind of response they would provide.

First I called a particular DME MAC Jurisdication, the rep listened and told me to call the PDAC, I called the PDAC and the rep told me that I need to call the specific DME MAC Jurisdiction...I explained that I just got off the phone with them and they told me to call the PDAC. The rep said she didn't know why they told me that, but to call them back. I called the DME MAC Jurisdiction back and got another rep on the phone and this rep gave me the answer I was looking for, and confirmation that my thought process was accurate.

I gave the rep the specific L3310 HCPCS Code and she proceeded to discuss the LCD Medical Policies for footwear. I told her that I know the medical policies, I know what it says, have it right in front of me, and I understood what she was saying; however, I told her that it is my opinion that the Medical Policies do not specifically exclude that LCode from coverage and she agreed. The story goes on...

In a nutshell, I wanted to hear her say and agree with me that the Medical Policies for O&P devices had quite a few "Gray Areas" and were not specific relating to the majority of LCodes, and that the Modifiers can be somewhat tricky when the footwear policy indicates that you are to use the "KX" modifier only if the shoe or modifications is/are an integral part of the brace. She agreed with me and she mentioned looking for "Key Words" in the LCD's. She also mentioned that you have to use the "KX" modifier if you have the documentation on file, regardless if the item is an integral part of a brace or not. BUT...she also stated that the "GA" modifier is a good choice, too, indicating that you have a properly executed ABN Form on file to protect the company if the item gets denied for any reason as "Not Deemed Medically Necessary".

Just as I always stress...it is important to justify the medical necessity, and it is so important to use the "KX" modifiers if you have documentation to back up your claim for any HCPCS Codes not on the "Non-Covered" list. If medically justified, and if the HCPCS Code is not excluded as a non-covered item(s), then the item(s) should be covered if you can prove the item is medically necessary and use the correct diagnosis codes and modifiers to support your claim.

The key here is...L3310 has a Medicare allowable reimbursement amount, not indicated on the Non Covered List of HCPCS Codes, and IT IS NOT A SHOE....IT IS A DEVICE THAT IS ADDED TO AN EXISTING SHOE. Hmmmmmmmmm, I can see why some folks have billing and reimbursement problems.

This is specifically, one reason why I chose to cover Medical Policies, Billing and Reimbursement for my 5th Annual Claims & Billing Symposium agenda for 2009...to get those claims paid, and on first claims submission.

As for the "KX" modifier...I find it absolutely ridiculous that some jurisdictions discourage the use of the "KX" modifier, excluding specific LCD's that indicate otherwise. Especially, when the LCD Medical Policies CLEARLY TELL DMEPOS PROVIDERS THAT YOU MUST HAVE DETAILED PRESCRIPTIONS AND "SUFFICIENT" MEDICAL DOCUMENTATION IN YOUR PATIENT'S MEDICAL RECORD. Needless to say, keep those Thursday Medicare Employee Training Programs going!