CO Regulatory Compliance & Reimbursement Flashcards

The HCPCS L-code L1906 describes which type of orthotic device?

Answer: AFO, spring wire (dorsiflexion assist calf band)

L1906 describes an AFO, spring wire (dorsiflexion assist type) with calf band, prefabricated, off-the-shelf — used for foot drop management.

When billing Medicare for a custom-fabricated orthosis, the claim must include documentation that demonstrates which of the following?

Answer: Medical necessity, a valid prescription, and compliance with applicable LCD criteria

Medicare claims for custom orthoses require documentation of medical necessity, a valid physician prescription, and compliance with the relevant Local Coverage Determination (LCD) criteria.

A Local Coverage Determination (LCD) for orthotics is issued by:

Answer: A Medicare Administrative Contractor (MAC) for their jurisdiction

Medicare Administrative Contractors (MACs) issue LCDs that define the coverage criteria, diagnosis codes, and documentation requirements for orthotic claims within their geographic jurisdiction.

Under the Competitive Bidding Acquisition Program (CBAP), which orthotic items are typically excluded from competitive bidding requirements?

Answer: Custom-fabricated orthoses requiring an individual patient model

Custom-fabricated orthoses requiring an individually made positive model are generally excluded from competitive bidding because their custom nature cannot be competitively bid like off-the-shelf items.

Which organization accredits orthotic and prosthetic facilities and is recognized by CMS for purposes of Medicare supplier accreditation?

Answer: The Board of Certification/Accreditation (BOC)

BOC (Board of Certification/Accreditation) is a CMS-approved accreditation organization for O&P facilities, and ABC accreditation is also recognized — facility accreditation is required for Medicare supplier status.

Upcoding in orthotic billing — billing for a higher-level device than was actually provided — is prohibited under which federal statute?

Answer: The False Claims Act (FCA)

The False Claims Act prohibits knowingly submitting false or fraudulent claims to federal health care programs, including billing Medicare for a higher-level device than was actually provided.