CO CO Regulatory Compliance & Reimbursement 2 — Questions and Answers
Question 1: The HCPCS L-code L1906 describes which type of orthotic device?
- Ankle-foot orthosis, posterior solid ankle, custom fabricated
- AFO, spring wire (dorsiflexion assist calf band) (Correct answer)
- Knee-ankle-foot orthosis, double upright, custom
- Wrist-hand orthosis, without joints, custom
Correct 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.
Question 2: When billing Medicare for a custom-fabricated orthosis, the claim must include documentation that demonstrates which of the following?
- The patient has private insurance as primary payer
- Medical necessity, a valid prescription, and compliance with applicable LCD criteria (Correct answer)
- The device was manufactured outside the United States
- The device cost exceeds $500 retail value
Correct 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.
Question 3: A Local Coverage Determination (LCD) for orthotics is issued by:
- The American Orthotic and Prosthetic Association (AOPA)
- A Medicare Administrative Contractor (MAC) for their jurisdiction (Correct answer)
- The Department of Veterans Affairs
- The Joint Commission on Accreditation of Healthcare Organizations
Correct 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.
Question 4: Under the Competitive Bidding Acquisition Program (CBAP), which orthotic items are typically excluded from competitive bidding requirements?
- Off-the-shelf prefabricated AFOs
- Custom-fabricated orthoses requiring an individual patient model (Correct answer)
- Standard diabetic shoe insoles
- Prefabricated cervical collars
Correct 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.
Question 5: Which organization accredits orthotic and prosthetic facilities and is recognized by CMS for purposes of Medicare supplier accreditation?
- The American Physical Therapy Association (APTA)
- The Board of Certification/Accreditation (BOC) (Correct answer)
- The National Commission on Orthotic and Prosthetic Education (NCOPE)
- The American Occupational Therapy Association (AOTA)
Correct 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.
Question 6: Upcoding in orthotic billing — billing for a higher-level device than was actually provided — is prohibited under which federal statute?
- The False Claims Act (FCA) (Correct answer)
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Stark Law (Physician Self-Referral Law)
- The Anti-Kickback Statute (AKS)
Correct 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.
CO CO Regulatory Compliance & Reimbursement 2
The HCPCS L-code L1906 describes which type of orthotic device?