February Educational Update
The 8 Keys to Getting Paid
As the contracted entity for our health plan partners Integra follows all CMS guidelines. This includes submitting the appropriate documentation at the time your claims are submitted. By submitting these 8 key pieces of information with your claim, you will be on your way to fewer denials, and a quicker turnaround time!
- Copy of patient’s insurance card- must include any secondary or co-insurance information as well
- Signed and dated physician order and/or prescription
- Signed and dated delivery ticket
- Signed and dated letter of medical necessity
- Signed and dated patient consent form
- Signed and dated patient assignment form
- Patient medical history form
- Provider patient contact history
Local Coverage Determination
Do you have the latest LCD for Ankle-Foot/Knee-Ankle-Foot Orthosis? If not, be sure to e-mail Nicole Robinson on our Network Development Team at email@example.com for the latest on; bill type codes, revenue codes, modifiers, prescription requirements, and much more!
Prescription Footwear Benefit Coverage
Prescription footwear is orthopedic shoes, shoe modifications or shoe additions. Benefit coverage is limited to:
- Children under 21 years of age who require orthopedic footwear to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot; to support a weak or deformed structure of the ankle or foot.
- When a shoe is attached to a lower limb orthotic brace. Prior Approval is required for beneficiaries who are age 21 and older, using only codes L3224 and L3225 and any addition and/or modifications to those shoe codes.
- As a component of a comprehensive diabetic treatment plan to treat amputation, or pre-Presfulcerative calluses, or peripheral neuropathy with evidence of callus formation of either foot, or a foot deformity or poor circulation. For DVS authorization and billing, see below for codes limited to shoes, inserts and/or modifications for diabetics only.
A5500 # For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe.
A5501 # For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient’s foot (custom-molded shoe), per shoe.
A5503 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe.
A5504 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe
A5505 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe.
A5506 # For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe.
A5507 # For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth inlay shoe or custom-molded shoe, per shoe.
A5512 # For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each
A5513 # For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer, (or higher), includes arch filler and other shaping material, custom fabricated, etc.
Questions may be directed to the Division of Provider Relations and Utilization Management, 1-800-342-3005 option 1.
KX Modifier Billing Reminder
Below is a list of LCDs which include a KX modifier requirement for some or all items within that specific LCD. Use of the KX modifier with any other DMEPOS is inappropriate language.
Please note that repeatedly billing incorrect or missing modifiers will result in a mandatory training session with the Integra Partners billing department. If you have questions or concerns regarding the appropriateness of modifiers please e-mail Nora Strong, Supervisor of Billing & Senior Claims Resolution Specialist at firstname.lastname@example.org.
- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Automatic External Defibrillators
- Cervical Traction Devices
- External Infusion Pumps
- Glucose Monitors
- High Frequency Chest Wall Oscillation Devices
- Hospital Beds
- Immunosuppressive Drugs
- Knee Orthosis
- Manual Wheelchair Bases
- Negative Pressure Wound Therapy Devices
- Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
- Oral Appliances for Obstructive Sleep Apnea
- Orthopedic Footwear
- Patient Lifts
- Positive Airway Pressure Devices
- Power Mobility Devices
- Pressure Reducing Support Surfaces
- Refractive Lenses
- Respiratory Assist Devices
- Speech Generating Devices
- Therapeutic Shoes for Persons with Diabetes
- Transcutaneous Electrical Nerve Stimulators (TENS)
- Urological Supplies
- Wheelchair Options and Accessories
- Wheelchair Seating
Questions may be directed to the Division of Provider Relations and Utilization Management, 1 800 342-3005, option 1.