COC Coding, Billing & Reimbursement 1 — Questions and Answers
Question 1: Which coding system is primarily used when billing orthotic and prosthetic devices to Medicare?
- CPT codes
- ICD-10-CM codes
- HCPCS Level II L-codes (Correct answer)
- DRG codes
Correct answer: HCPCS Level II L-codes
HCPCS Level II L-codes are the alphanumeric codes specifically designated for billing orthotic and prosthetic devices to Medicare and other payers.
Question 2: What does the acronym PDAC stand for in the context of O&P billing?
- Prosthetic Device Approval Commission
- Pricing, Data Analysis and Coding (Correct answer)
- Primary Documentation and Claims
- Prosthetic and Device Authorization Center
Correct answer: Pricing, Data Analysis and Coding
PDAC stands for Pricing, Data Analysis and Coding, the Medicare contractor that verifies appropriate HCPCS code assignments for DME and O&P items.
Question 3: Which document must a Medicare beneficiary sign if an O&P item may not be covered by Medicare?
- Certificate of Medical Necessity (CMN)
- Advance Beneficiary Notice (ABN) (Correct answer)
- Prior Authorization Request
- Assignment of Benefits Form
Correct answer: Advance Beneficiary Notice (ABN)
An Advance Beneficiary Notice (ABN) must be signed by the Medicare beneficiary before service when the provider believes Medicare may deny coverage, giving the patient the option to receive the item and pay out of pocket.
Question 4: What is the primary purpose of a Local Coverage Determination (LCD) in O&P billing?
- To establish national payment rates for all private payers
- To define Medicare coverage criteria and coding guidance for specific items within a region (Correct answer)
- To authorize prior approval for high-cost prosthetic devices
- To determine the beneficiary's annual cost-sharing responsibility
Correct answer: To define Medicare coverage criteria and coding guidance for specific items within a region
An LCD defines Medicare coverage criteria, coding guidance, and documentation requirements for specific items or services within a Medicare Administrative Contractor's jurisdiction.
Question 5: On the CMS-1500 claim form, where is the referring physician's NPI number typically entered?
- Box 17b (Correct answer)
- Box 24j
- Box 33a
- Box 21
Correct answer: Box 17b
The referring physician's NPI number is entered in Box 17b of the CMS-1500 claim form, adjacent to Box 17 which contains the referring provider's name.
Question 6: Which Medicare functional classification (K-level) is assigned to a patient who has the potential to ambulate with variable cadence as a community ambulator?
- K1
- K2
- K3 (Correct answer)
- K4
Correct answer: K3
K3 is assigned to community ambulators who have the ability to traverse most environmental barriers and may use a prosthesis for activities beyond simple locomotion, including variable cadence ambulation.
Question 7: Which HCPCS modifier is appended to a claim to indicate that an O&P service was performed on the right side of the body?
- -LT
- -RT (Correct answer)
- -50
- -GX
Correct answer: -RT
The -RT modifier indicates that the service or device was applied to the right side of the body, and -LT is used for the left side.
COC Coding, Billing & Reimbursement 1
Which coding system is primarily used when billing orthotic and prosthetic devices to Medicare?