“A claim for orthotics, L3000 right and L3000 left is being sent to Care-First Blue Cross Blue Shield Washington DC. Question: is Place of Service still #12 (Home)?
I ask because a claim was recently denied for POS 12 for orthotics (too early to know if changing it to Place of Service 11 for Office was successful.
Additionally, the patient presents with an unrelated new problem on the same date of service and this is how we are billing. Are we right?
POS 11 99213 modifier 25
POS 12 L3000 RT
POS 12 L3000 LT (is XS needed?)”
With respect to orthotics, Medicare Administrative Contractors/Traditional Medicare do not reimburse for orthotics. They are classified as statutorily non-covered. As a rule, Medicare Advantage Plans do not reimburse for orthotics either. However, certain Medicare Advantage Plans have expanded coverage and reimbursement for orthotics is a possibility and needs to be confirmed with the plan in question. So, the bottom line is, what is the proper way to bill for orthotics for the commercial health insurance plans that do cover orthotics?
With respect to the Place of Service code, Traditional Medicare requires Place of Service Code 12, the patient's Home for DME. This does not guarantee that the different commercial health insurance plans require Place of Service 12. Therefore, it is important to contact the individual commercial health insurance carrier to find out the Place of Service Code that they require. Often, it is Place of Service Code 11, Office.
When you look at the sample coding scenario that was posted, I would make a few changes. First of all, a 25 modifier does not need to be appended to E/M code 99213 to indicate a significant, separately identifiable E/M service. L3000 is not a CPT/procedure code. It is a HCPCS Level II code that represents a supply, device, or DME.
As far as billing for L3000 is concerned, the orthotics or for that matter any DME should not be billed to the health insurance carrier until they are dispensed. Additionally, the health insurance carrier in question needs to be contacted in order to find out the following:
1. Should the orthotics be billed on 1 line or on 2 lines?
2. Should the KX modifier be appended to the L3000 codes? The KX modifier is defined as the following: DOCUMENTATION ON FILE - Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service. This modifier is used on all line items for claims that are submitted to the DMERC. Even though this is classified as a Medicare modifier, there are some commercial health insurance carriers that still require its use. This needs to be confirmed by the health insurance carrier as well.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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