“I know with Medicare and Medicaid you bill any DME the date of dispensing. I am curious about commercial insurance plans. Can you bill the day you cast for devices?”
With respect to billing, coding and documentation, on a specific date when a service is rendered to a patient, in order to submit a claim and be reimbursed for the service that was provided, the medical record documentation needs to demonstrate the following:
1. Specifically, the service that was provided and the reason(s) why the service that was provided were medically necessary.
2. The CPT codes and the ICD-10-CM codes that were used reflect specifically the service(s) that were provided and the reason(s) that they were provided
3. The claim that is submitted to the health insurance carrier is based upon the service(s) that were provided on that specific date of service.
The bottom line is that on a specific date of service, a provider can only bill for the service or services that were specifically provided on that date of service. When it comes to Durable Medical Equipment (DME), specifically Ankle Foot Orthoses (AFO), the AFO can only be billed on the date of service when it is dispensed and fit to the patient’s affected lower extremity. Without going into detail, when the LCD (L33681 – Ankle-Foot, Knee-Ankle-Foot Orthosis), the associated article for Ankle-Foot, Knee-Ankle-Foot Orthosis (A52547) and the article for the Standard Documentation Required For All Claims Submitted to DME MACs (A55426) are reviewed, it is quite apparent that the ONLY date that the AFO can be billed is on the date that it is dispensed and fit to the patient’s affected lower extremity.
Obviously, the above information pertains to traditional Medicare. Why would this be different for Medicare Advantage plans, Medicaid, or the commercial health insurance carriers? It is not different. On the date that the patient is cast for the device, the AFO has not even been ordered. How can you justify billing for something that has not even been made? You can’t.
It is all about the medical record documentation. You can only bill for the service or services that were specifically performed on the date of service in question and documented in the medical record.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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