CFO CFO Insurance & Billing 1 — Questions and Answers
Question 1: Which HCPCS code category is primarily used to bill for custom-fabricated foot orthotics?
- L-codes (Correct answer)
- A-codes
- E-codes
- K-codes
Correct answer: L-codes
L-codes (L3000–L3999) are the HCPCS Level II codes designated for orthotic devices including custom foot orthotics.
Question 2: A Certificate of Medical Necessity (CMN) for orthotics must be signed by which provider?
- The certified fitter
- The patient
- The ordering physician (Correct answer)
- The insurance adjuster
Correct answer: The ordering physician
The ordering physician must sign the CMN to certify that the orthotic device is medically necessary for the patient.
Question 3: What does the term 'prior authorization' mean in the context of orthotic billing?
- Approval obtained after service is rendered
- Insurance approval obtained before providing the orthotic device (Correct answer)
- A second fitting session approval
- A refund request form
Correct answer: Insurance approval obtained before providing the orthotic device
Prior authorization is pre-approval from the insurance payer required before providing certain orthotic devices to ensure coverage.
Question 4: Under Medicare, what documentation is required in a patient's chart to support billing for a custom ankle-foot orthosis (AFO)?
- Patient's verbal confirmation
- Detailed written order, diagnosis, and clinical notes justifying medical necessity (Correct answer)
- Insurance card copy only
- A photograph of the device
Correct answer: Detailed written order, diagnosis, and clinical notes justifying medical necessity
Medicare requires a detailed written order, a valid diagnosis, and clinical notes demonstrating medical necessity for custom AFO reimbursement.
Question 5: Which modifier is commonly appended to an HCPCS code to indicate that a custom orthosis was fabricated from a cast or scan of the patient's limb?
- Modifier KX (Correct answer)
- Modifier KE
- Modifier RT
- Modifier LT
Correct answer: Modifier KX
Modifier KX is used with Medicare claims to indicate that the supplier has documentation on file confirming medical necessity requirements are met.
Question 6: What is a Local Coverage Determination (LCD) in the context of orthotic reimbursement?
- A state law governing fitter licensing
- A Medicare Administrative Contractor policy defining coverage criteria for specific items (Correct answer)
- A patient consent form
- A billing software module
Correct answer: A Medicare Administrative Contractor policy defining coverage criteria for specific items
An LCD is a policy issued by a Medicare Administrative Contractor (MAC) that specifies coverage criteria, diagnosis codes, and documentation requirements for specific devices.
CFO CFO Insurance & Billing 1
Which HCPCS code category is primarily used to bill for custom-fabricated foot orthotics?