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

Prior authorization is formal approval from the insurance carrier obtained before delivering O&P services, confirming that the planned device will be covered and reimbursed.

Question 2

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

Accepted Answer

Part B (Medical Insurance)

Answer

Most prosthetic and orthotic devices are covered under Medicare Part B (Medical Insurance) when prescribed by a physician and deemed medically necessary.

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

The DMEPOS Fee Schedule establishes Medicare's allowed payment amounts for prosthetic and orthotic devices based on HCPCS L-codes.

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 a joint federal-state program administered individually by each state, resulting in significant variation in O&P coverage, limits, and reimbursement rates across states.

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

Medicare Part B pays 80% of the approved amount for covered O&P services after the deductible, leaving the beneficiary responsible for 20% co-insurance.

(CPO) Certified Prosthetist Orthotist Practice Test

(CPO) Certified Prosthetist Orthotist Practice Test

CPO Documentation, Coding & Reimbursement 3