CO Regulatory Compliance & Reimbursement Flashcards

The Anti-Kickback Statute (AKS) is relevant to orthotics practice primarily because it prohibits:

Answer: Offering or receiving anything of value in exchange for referrals of Medicare/Medicaid patients

The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce or reward referrals of Medicare or Medicaid patients, which protects the integrity of the referral process.

When must a claim for a custom orthosis be submitted to Medicare under timely filing requirements?

Answer: Within 1 year of the date of service

Medicare requires that claims be filed within 1 calendar year (12 months) from the date of service; claims filed after this period are denied for untimely filing.

Under CMS policy, a prefabricated orthosis that requires 'minimal self-adjustment' by the patient may be billed as 'off-the-shelf' (OTS). What distinguishes an OTS device from a custom-fitted device?

Answer: OTS devices do not require skilled fitting by a certified orthotist, while custom-fitted do

OTS prefabricated devices can be used with minimal self-adjustment and do not require the skilled services of a certified orthotist for fitting, while custom-fitted prefabricated devices do require skilled fitting and adjustment.

What is the purpose of the 'Supplier Standards' that DMEPOS suppliers including orthotic practices must meet to maintain Medicare billing privileges?

Answer: To establish operational and ethical requirements ensuring suppliers can properly furnish covered items

CMS DMEPOS Supplier Standards establish minimum operational, ethical, and service requirements that suppliers must meet to maintain Medicare billing privileges and ensure quality patient care.

If a Medicare patient returns an orthosis within the rental/purchase window for DME, the orthotic supplier is required to:

Answer: Issue a refund or credit and notify the MAC of the returned item

When a covered item is returned, suppliers are required to refund any patient payments, cease billing, and report the return to the Medicare Administrative Contractor to avoid overpayment.

Which ICD-10-CM code range is most commonly used to support medical necessity for lower limb orthoses related to neurological conditions such as foot drop?

Answer: G00–G99 (Diseases of the nervous system)

ICD-10 codes in the G00–G99 range (diseases of the nervous system), such as G57.0 (lesion of sciatic nerve) or G83.1 (monoplegia), are commonly used to support medical necessity for neurologically-indicated lower limb orthoses.