CFO CFO Insurance & Billing 2 — Questions and Answers
Question 1: When billing Medicare for a prefabricated orthosis that requires fitting, which HCPCS code modifier indicates the item was off-the-shelf?
- Modifier NU (Correct answer)
- Modifier KD
- Modifier KP
- Modifier RR
Correct 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.
Question 2: A claim for an orthotic device is denied due to a 'missing modifier.' What is the most appropriate first step?
- Write off the balance
- File a corrected claim with the appropriate modifier attached (Correct answer)
- Call the patient for more insurance information
- Resubmit the same claim without changes
Correct 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.
Question 3: Which ICD-10 code category is most commonly used to justify orthotic fitting for a patient with diabetic peripheral neuropathy?
- M79.x (soft tissue disorders)
- E11.40 (Type 2 diabetes with diabetic neuropathy) (Correct answer)
- Z96.x (presence of implants)
- S90.x (superficial injury of ankle/foot)
Correct 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.
Question 4: What is the typical timely filing limit for Medicare Part B orthotic claims?
- 90 days from date of service
- 6 months from date of service
- 1 year from date of service (Correct answer)
- 2 years from date of service
Correct 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.
Question 5: 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?
- One pair
- Two pairs
- Three pairs (Correct answer)
- Five pairs
Correct 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.
Question 6: What does 'assignment' mean when a supplier accepts Medicare assignment for an orthotic?
- The supplier ships the device to the patient's home
- The supplier agrees to accept Medicare's approved amount as payment in full (Correct answer)
- The patient assigns their benefits to a family member
- The device is assigned a new HCPCS code
Correct 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.
CFO CFO Insurance & Billing 2
When billing Medicare for a prefabricated orthosis that requires fitting, which HCPCS code modifier indicates the item was off-the-shelf?