COF Insurance & Reimbursement 3

Question 1

A patient has Medicare as primary and Medicaid as secondary insurance. Which payer must be billed first?

Accepted Answer

Medicare, because it is always primary over Medicaid

Answer

Medicare is always primary over Medicaid; Medicaid acts as the payer of last resort and only covers costs remaining after Medicare pays.

Question 2

What is a Local Coverage Determination (LCD) and how does it affect orthotic billing?

Accepted Answer

A Medicare Administrative Contractor's policy defining when a specific item is covered in their jurisdiction

Answer

An LCD is issued by a Medicare Administrative Contractor (MAC) and establishes coverage criteria and ICD-10 diagnosis codes that support medical necessity for specific items.

Question 3

When billing Medicare for a custom-fabricated orthosis, which modifier is typically required to indicate the item was custom-made?

Accepted Answer

Modifier -KX

Answer

Modifier KX is appended to indicate that the documentation on file supports the medical necessity requirements specified in the LCD.

Question 4

What is the significance of the 'certificate of medical necessity' (CMN) for orthotic claims?

Accepted Answer

It is a standardized form some payers use to document and certify medical necessity for specific DME items

Answer

A CMN is a standardized form used by CMS for certain DME items to document that the item is medically necessary for the patient.

Question 5

A commercial insurance plan denies an orthotic claim stating the device is 'not medically necessary.' What is the appropriate first step?

Accepted Answer

Submit a formal appeal with supporting clinical documentation

Answer

The appropriate response to a medical necessity denial is to file a formal appeal with the clinical documentation supporting the physician's order.

(COF) Certified Orthotic Fitter Practice Test

(COF) Certified Orthotic Fitter Practice Test

COF Insurance & Reimbursement 3