CO CO Regulatory Compliance & Reimbursement 1 — Questions and Answers
Question 1: Which federal program sets the L-code system used to classify and bill orthotic devices in the United States?
- The Joint Commission (TJC)
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- The American Board for Certification in Orthotics (ABC)
- The Food and Drug Administration (FDA)
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS establishes and maintains the HCPCS Level II L-code billing system used to classify and reimburse orthotic and prosthetic devices under Medicare and Medicaid.
Question 2: Under Medicare policy, which documentation is required from the referring physician before a custom orthosis is considered medically necessary and reimbursable?
- A written order or prescription specifying the orthotic need (Correct answer)
- A signed insurance pre-authorization form only
- A completed ABC certification form
- A physical therapy evaluation summary
Correct answer: A written order or prescription specifying the orthotic need
Medicare requires a written order or prescription from a physician or eligible non-physician practitioner that specifies the orthotic device needed before the claim is considered for reimbursement.
Question 3: The ABC (American Board for Certification) credential for an orthotist is designated as:
- RO (Registered Orthotist)
- CO (Certified Orthotist) (Correct answer)
- LO (Licensed Orthotist)
- BOC-O (Board Certified Orthotist)
Correct answer: CO (Certified Orthotist)
The American Board for Certification in Orthotics, Prosthetics, and Pedorthics awards the CO (Certified Orthotist) credential to practitioners who pass the required written and patient management examinations.
Question 4: A Certificate of Medical Necessity (CMN) for a spinal orthosis under Medicare must be signed by:
- The certified orthotist who fabricated the device
- The patient or their legal guardian
- The treating physician or eligible non-physician practitioner (Correct answer)
- The insurance carrier's medical director
Correct answer: The treating physician or eligible non-physician practitioner
A CMN must be completed and signed by the treating physician or eligible non-physician practitioner, not the orthotist, to validate the medical necessity of the device for Medicare reimbursement.
Question 5: Under HIPAA regulations, a patient's orthotic records may be shared with a new treating physician without additional written authorization because this falls under:
- Marketing and fundraising activities
- Treatment, payment, and health care operations (TPO) (Correct answer)
- Research purposes with IRB waiver
- Public health reporting requirements
Correct answer: Treatment, payment, and health care operations (TPO)
HIPAA's Privacy Rule permits disclosure of protected health information (PHI) for treatment, payment, and health care operations without additional patient authorization.
Question 6: Which federal law requires orthotic practices to maintain an Advance Beneficiary Notice (ABN) process for Medicare patients when the service may not be covered?
- The Social Security Act Section 1862 (Correct answer)
- The Americans with Disabilities Act (ADA)
- The Rehabilitation Act of 1973
- OSHA regulations
Correct answer: The Social Security Act Section 1862
Section 1862(a)(1) of the Social Security Act defines Medicare coverage requirements, and the ABN process is mandated by CMS to inform patients of potential non-coverage before service delivery.
CO CO Regulatory Compliance & Reimbursement 1
Which federal program sets the L-code system used to classify and bill orthotic devices in the United States?