COF Insurance & Reimbursement 2 — Questions and Answers
Question 1: Which Medicare benefit covers custom orthotics for a diabetic patient with peripheral neuropathy?
- Medicare Part A
- Medicare Part B (Correct answer)
- Medicare Part C only
- Medicare Part D
Correct answer: Medicare Part B
Medicare Part B covers durable medical equipment including custom orthotics when medically necessary.
Question 2: What is the purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?
- To authorize payment directly to the provider
- To inform the patient that Medicare may not cover the item so they can decide whether to proceed (Correct answer)
- To request prior authorization from Medicare
- To document the patient's diagnosis for claim submission
Correct answer: To inform the patient that Medicare may not cover the item so they can decide whether to proceed
An ABN notifies a Medicare beneficiary that a service may not be covered so they can choose to receive it and pay out-of-pocket if denied.
Question 3: Under Medicare, which HCPCS code range primarily covers orthotic devices?
- A-codes (A0000–A9999)
- L-codes (L0000–L4999) (Correct answer)
- E-codes (E0100–E9999)
- K-codes (K0001–K0900)
Correct answer: L-codes (L0000–L4999)
L-codes are the HCPCS Level II codes specifically designated for orthotic and prosthetic devices.
Question 4: A claim is denied with remark code CO-57. What does this typically indicate?
- The claim was filed after the timely filing deadline (Correct answer)
- The provider is not enrolled in the payer's network
- The service is not covered by the patient's plan
- The diagnosis does not support medical necessity
Correct answer: The claim was filed after the timely filing deadline
CO-57 (or similar timely filing denials) indicates the claim was submitted after the payer's deadline for filing.
Question 5: What does 'coordination of benefits' (COB) mean in the context of orthotic billing?
- Coordinating the fitting schedule between the orthotist and physician
- Determining which payer pays first and how secondary insurance covers remaining costs (Correct answer)
- Combining multiple HCPCS codes on a single claim
- Coordinating benefits between Medicare Part A and Part B
Correct answer: Determining which payer pays first and how secondary insurance covers remaining costs
COB is the process of determining the order of payment when a patient has more than one insurance plan to prevent duplicate payments.
Question 6: Which documentation is typically required by Medicare to support a claim for a custom ankle-foot orthosis (AFO)?
- Only the HCPCS code and billed amount
- A physician's prescription, medical records showing diagnosis, and proof of delivery (Correct answer)
- Patient's signed consent form only
- The orthotist's credentials and state license number only
Correct answer: A physician's prescription, medical records showing diagnosis, and proof of delivery
Medicare requires a detailed written order from the treating physician, supporting clinical documentation, and a proof of delivery for custom orthotics.
Question 7: What is the Medicare fee schedule payment basis for most orthotic devices?
- Cost-plus-markup model based on material costs
- A percentage of the supplier's usual and customary charge
- A set fee based on the HCPCS code, adjusted by geographic locality (Correct answer)
- Competitive bidding prices regardless of location
Correct answer: A set fee based on the HCPCS code, adjusted by geographic locality
Medicare pays for orthotics based on a fee schedule amount tied to the specific HCPCS code, adjusted by a geographic practice cost index (GPCI).
COF Insurance & Reimbursement 2
Which Medicare benefit covers custom orthotics for a diabetic patient with peripheral neuropathy?