CPO Documentation, Coding & Reimbursement 3

Question 1

What is 'prior authorization' in the context of O&P reimbursement?

Accepted Answer

Insurance carrier approval obtained before providing a service to confirm coverage

Answer

The CPO's internal approval process before beginning fabrication

Answer

The treating physician's signature on the prescription form

Answer

Medicare's automatic pre-approval assigned to all L-codes

Question 2

Under which Medicare benefit category are most prosthetic and orthotic devices covered?

Accepted Answer

Part B (Medical Insurance)

Answer

Part A (Hospital Insurance)

Answer

Part C (Medicare Advantage Plans only)

Answer

Part D (Prescription Drug Coverage)

Question 3

Which fee schedule does Medicare use to determine reimbursement rates for prosthetic and orthotic devices?

Accepted Answer

DMEPOS (Durable Medical Equipment Prosthetics Orthotics and Supplies) Fee Schedule

Answer

Physician Fee Schedule (PFS)

Answer

Ambulatory Payment Classification (APC) schedule

Answer

Hospital Outpatient Prospective Payment System (HOPPS)

Question 4

How does Medicaid O&P coverage typically differ from Medicare coverage?

Accepted Answer

Medicaid coverage for O&P varies by state because each state administers its own program

Answer

Medicaid is federally standardized and always mirrors Medicare benefits

Answer

Medicaid universally covers more O&P devices than Medicare in all states

Answer

Medicaid does not cover any prosthetic or orthotic devices in any state

Question 5

What is the standard Medicare Part B co-insurance percentage that patients are responsible for on covered O&P devices?

Accepted Answer

20% of the Medicare-approved amount

Answer

10% of the Medicare-approved amount

Answer

15% of the Medicare-approved amount

Answer

25% of the Medicare-approved amount

Question 6

What is 'balance billing' in the context of O&P reimbursement, and how does it apply to Medicare-participating providers?

Accepted Answer

Billing the patient for the difference between the provider's charge and the insurance payment, which is restricted for Medicare participants

Answer

Splitting a single large claim into multiple smaller billing submissions

Answer

Documenting the balance of fabrication materials on the claim form

Answer

Billing Medicare and Medicaid simultaneously for the same service

Question 7

How does Medicare's Competitive Bidding Acquisition Program (CBIC) affect O&P suppliers in covered geographic areas?

Accepted Answer

Selected suppliers win contracts through a bidding process and set payment amounts, limiting which suppliers can serve Medicare beneficiaries in those areas

Answer

All O&P devices in every region are subject to competitive bidding contracts

Answer

CPOs holding ABC or BOC certification are entirely exempt from competitive bidding

Answer

Competitive bidding applies only to rented DME items, never to purchased O&P devices