CFO Insurance & Billing Flashcards

When billing Medicare for a prefabricated orthosis that requires fitting, which HCPCS code modifier indicates the item was off-the-shelf?

Answer: Modifier NU

Modifier NU indicates a new item is being purchased, while off-the-shelf prefabricated orthotics are billed using codes that reflect no custom fitting was performed.

A claim for an orthotic device is denied due to a 'missing modifier.' What is the most appropriate first step?

Answer: File a corrected claim with the appropriate modifier attached

When a claim is denied for a missing modifier, the correct action is to file a corrected claim (CMS-1500 with 'corrected' indicated) including the required modifier.

Which ICD-10 code category is most commonly used to justify orthotic fitting for a patient with diabetic peripheral neuropathy?

Answer: E11.40 (Type 2 diabetes with diabetic neuropathy)

E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) is the primary diagnosis code used to support medical necessity for diabetic foot orthotics.

What is the typical timely filing limit for Medicare Part B orthotic claims?

Answer: 1 year from date of service

Medicare Part B requires claims to be submitted within 1 year (12 months) from the date of service to be considered for payment.

Under the Therapeutic Shoe Bill (Medicare Part B), how many pairs of custom-molded inserts is a qualifying diabetic patient entitled to per calendar year?

Answer: Three pairs

Under Medicare's Therapeutic Shoe Benefit, qualifying diabetic patients may receive up to three pairs of custom-molded inserts per calendar year.

What does 'assignment' mean when a supplier accepts Medicare assignment for an orthotic?

Answer: The supplier agrees to accept Medicare's approved amount as payment in full

Accepting assignment means the supplier agrees to accept Medicare's approved payment amount as full payment, and cannot charge the beneficiary more than the co-insurance and deductible.