Medicare

“We had a patient that was dispensed an ankle foot orthoses (AFO) about 4 1/2 years ago. This device broke and he was having difficulty walking without it. We dispensed a new AFO and it was denied as the original wasn’t 5 years old. We had a very long telephone conversation with Medicare along with the patient and his attorney. Unfortunately, Medicare wouldn’t budge as they said he should have gone back to the provider of the original brace, even though it was in another state. We did have an ABN, but the patient said that he’s not going to pay for the replacement. We are working with him now to at least get our lab costs. Unfortunately, appeals don’t always work. We requested a peer-to-peer, but after several months we have not heard anything as they are too backlogged! I suspect that there are other stories like this out there. I wish we could just tell patients what it costs and they hand over their credit cards.”

“On all of our patients that qualify for routine foot care with the diagnosis of I70.203 Atherosclerosis we send an “Atherosclerosis Letter” to the patient’s treating doctor with our findings and ask them to sign if they agree with our findings. 99% of the time the doctors send the letter back signed. We have always done this in accordance with the routine foot care LCD that in the past stated that we had that letter or documentation from the treating physician in our patient’s chart “in a timely manner.” Recently we have had some doctors sending back the letter, disagreeing with our findings. We have already billed the services from their initial visit knowing or thinking that we will have that documentation for the next appointment in 9 weeks. This led me to research the LCD again, and I am unable to locate the verbiage that was used before about the patient’s other treating doctors agreeing and signing anything. It merely states that we have our findings in the note and the other doctor’s name on the claim to Medicare. Do we need that letter agreed to and signed from the patient’s other doctor? Do other offices also send this “letter” to get that info? Any input is greatly appreciated.”

“Can anyone offer advice or input for a telemedicine visit? The telemedicine visit was performed to update a history and physical prior to surgery AND it is performed by a medical assistant.”

“I am looking for a relatively concise explanation regarding Medicare’s policy on palliative care and coverage for diabetics and non-diabetics. As of late, fewer and fewer charges for nail debridement and keratosis debridement are being reimbursed. I have tried to search through Medicare’s guidelines but there is not enough time in a year to sift through the documentation. Is there such a thing as a concise explanation for Medicare’s guidelines for palliative care and CPT codes with ICD-10 codes?”

“I documented a women’s size 10.5 shoe measurement in my Medicare note and then ordered the shoes from my diabetic shoe supplier. The supplier mailed me a pair of men’s 8.5 shoes since they are essentially the same size as a woman’s 10.5. In an audit, would Medicare have a problem with the size discrepancy, since I have to document that I dispensed a men’s 8.5 rather than the originally fitted women’s 10.5?”

“I had a patient present to the clinic with multiple, minimally displaced toe fractures. She has Medicare and we are planning to treat all four of these conservatively. When and how do I use CPT code 28510?”

Beginning in 2022, if you order Medicare Part B advanced diagnostic imaging services, you must consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims. When we use “you”, we are referring to physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to Medicare beneficiaries and billing Medicare Administrative Contractors (MACs).

I am trying to educate my physician about the documentation requirements for CPT code 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?

Here’s a fun fact that is wreaking havoc in practices with a large volume of patients over 65, especially where facility work (SNFs, assisted living, nursing homes) is involved: Enrollment in Medicare Advantage Plans has DOUBLED over the past decade It has been reported so far in 2021 that approximately 43% (up from 39% in 2020; see graph below) of the 63 million individuals who “have Medicare” actually receive their benefits via an Advantage Plan. And just when you thought you were finished updating patient insurance information in January and February, if those Medicare Advantage patients decide that the plan they chose was not the right fit and they want to go back to traditional Medicare, they have until March 31st to do so.

“Can you evaluate and manage onychomycosis without debridement for the purpose of treating onychomycosis for an established patient? This would be in the absence of pain and underlying conditions, specifically with Medicare patients. Is it a covered condition for just evaluation and management? Would tinea pedis be covered as a sole diagnosis for evaluation and management?”