Do You Know Medical Billing? 

CBS Medical Billing FAQs From O&P Practitioners And Health Care Administrators

The world of medical billing is not always the easiest to navigate. Between complex CPT codes, ever-changing compliance standards, and every day complications that come with health care, practitioners and administrators are often left wondering what’s going on with their claims. We put together this list of our top 20 medical billing FAQs to serve as a resource in the rapidly evolving healthcare industry for anyone who could use help with revenue cycle management and medical billing compliance. In this blog, we delve into the common questions that arise within O&P medical billing, providing you punchy answers that can help you better understand the scenario. 

That said, very few medical billing situations have a 1 size fits all solution, so, if you’re still not sure about the issue, we encourage you to connect with us for further clarification. 

TOP 20 Medical Billing FAQS

Do Miscellaneous Codes Ever Get Paid?

Yes. Despite the common myth, miscellaneous codes can be paid when properly documented with medical necessity and pricing justifications.

How Often do I Need to Bill Medicare to Keep my Medicare Number?

At least once in a 12-month period. A provider’s PTAN is deactivated when an organization has not billed Medicare for 4 consecutive quarters.

If I’m billing a non-covered code to Medicare, do I still need to comply with Medicare’s regulations?

Yes. All claims, regardless of code coverage, must adhere to Medicare’s standard documentation requirements. Compliance is the key to smooth claims. 

I’m getting audits from commercial payers… Can they do that?

Yes, unfortunately they can. Audit rights are often outlined in your contract with the payer. That’s why it’s so important to know exactly what your contract says! Our founder, Erin Camaratta, offers specialized training to help you and your team better understand contacts – if you’re interested, be sure to ask her about it. 

Why did a claim for a knee brace be denied when the medical record says the patient has instability?

It could be due to the documentation of the instability. The instability must be documented by examination and described objectively (e.g., varus/valgus instability, anterior/posterior drawer test). Subjective descriptions or those only noted in the patient’s history won’t satisfy the policy criteria.

Why did my prosthetic claim get recouped by Medicare if the patient was inpatient?

It depends on where the patient was admitted. Billing responsibilities differ if the patient is in a Hospital versus a Skilled Nursing Facility (SNF).

What is the limit on how old physician notes can be?

Generally, the documentation should be within 6-12 months, depending on the specific policy criteria. Timely documentation is defined as records within the preceding twelve months unless specified otherwise.

The physician notes I received are dated after the prescription, is that okay?

No. The physician’s notes justifying medical necessity must be dated on or before the initial prescription to establish continued medical need.

Can the physician amend their medical records?

Yes. Amendments, corrections, or delayed entries must be clearly identified, dated, and authored, and original content must be distinguishable. Our Chief Clinical Officer, Ken Cornell CO (certified orthotist), is an expert when it comes to crafting effective physicians notes and establishing proper practices for practitioners – if this is an area your operation is struggling with, be sure to ask CBS about our new Executive Support Services. 

The SWO has the patient’s K-Level or says the item is custom; is that enough justification for payment?

No. Supplier-prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity. These must be corroborated by information in the medical record.

What needs to be documented to justify a same/similar replacement?

Document the reason for replacement (loss/theft, irreparable damage, change in condition), and ensure all required information supporting the need for replacement is included and corroborated in the medical record.

How can we ensure compliance when billing for upgraded orthotic and prosthetic components?

Ensure compliance by thoroughly documenting the medical necessity for upgraded components, including detailed clinical evaluations and justifications that align with payer-specific requirements. Remember to include specific documentation requirements for the medical necessity when components exceed standard care specifications.

What are the documentation requirements for tele-health consultations related to O&P fittings and follow-ups?

Telehealth usage has dramatically risen in the post-pandemic era of healthcare. Documentation for tele-health consultations should include detailed records of the virtual encounter, patient consent for tele-health, and specific notes on the assessment and recommendations made during the consultation.

What are the best practices for managing denials related to O&P claims, and how can we effectively appeal these decisions?

Best practices include meticulous review of the denial reasons, gathering all necessary documentation, and submitting a well-drafted appeal that addresses each point of contention outlined by the payer. One way CBS can support your medical practice is by helping you navigate the appeals process by better knowing the standard timelines and necessary documents that will be required to resolve denials.

Can you provide an example of non-covered O&P services under Medicare and how to communicate these exceptions to patients?

Understanding which services are not covered and how to manage patient expectations regarding out-of-pocket costs is essential. A great example of non-covered services would be devices considered convenience items, like cosmetic enhancements. The best way to ensure clarity between providers and patients about these exceptions is by not only discussing the potential out-of-pocket costs, but even providing written disclosures about them. 

What specific training or certifications are recommended for billing staff handling O&P claims to ensure expertise and compliance?

Medical billing staff and/or practice administrators should pursue certifications such as Certified Professional Coder (CPC) and specialized training in O&P billing to ensure they are well-versed in the unique aspects of O&P coding and reimbursement guidelines. Of course, another great way to ensure your medical practices billing requirements are taken care of is by hiring the pros at CBS Medical Billing. We’ll not only handle your claims, but provide essential training to your in-house administrators so we can all work together as effectively as possible. You can contact us and ask about our in-person and online training programs any time! 

How does the use of advanced materials or technology in prosthetics, like myoelectric components, affect billing and reimbursement?

Advanced prosthetic components like myoelectric devices often require specific coding and detailed justification for reimbursement, highlighting their necessity over standard options based on the patient’s medical condition and functional needs.

What are the most common reasons for claim rejections in general medical practice, and how can we prevent them?

Common reasons include incorrect patient data, expired codes, and lack of prior authorization. Prevention can be managed by regular training, use of updated software for claim submissions, and diligent verification processes.

What are the latest updates to ICD-10 and CPT codes that our practice needs to be aware of?

Staying updated with coding changes is essential for accurate billing and compliance. Practices must stay updated with annual changes to ICD-10 and CPT codes which can include new codes, revisions, and deletions to accurately reflect current medical practices and ensure compliant billing.

Can you explain the process and benefits of outsourcing medical billing? What should we look for in a billing service provider?

Outsourcing medical billing can offer benefits such as reduced overhead costs, enhanced billing expertise, and improved claim accuracy. Look for providers with strong track records, expertise in your specialty, and robust compliance practices. At CBS Medical Billing and Consulting, we check those key boxes and some – in fact, we’ve even been called the leading provider of outsourced medical billing services in the O&P industry and beyond. 

Now You Know Medical Billing…Right?

If only it were that easy…

We hope that this Medical Billing FAQ blog has shed some light on your most pressing question. With these short answers, ideally you and your administrative team are able to handle your billing needs more effectively and compliant. However, know we’re here to help.

Many of these questions are sourced from the 15 years we’ve spent providing medical billing support to our friends in the O&P industry, but we serve all kinds of health care providers. This industry is always evolving, adapting, adjusting – it’s important to stay updated and actively educated on medical billing best practices in order to maintain successful and compliant healthcare practices. 

At CBS Medical Billing & Consulting, part of our purpose is to do just that – serve our community as educators. Whether you keep coming back to this blog, or you hire us to come give a private staff training session to your team, we’re a resource to you. And If you find this information helpful, share it with someone who might also benefit: a colleague, a practitioner, an administrator, someone new in the field. 

For more detailed insights and assistance, contact CBS Medical Billing to explore our services tailored specifically for the O&P community. Let us help you streamline your billing processes and enhance your compliance strategies.

Stay informed, stay compliant, and transform your practice’s financial health with the expertise from CBS Medical Billing – your practice’s missing piece.

Get in touch today to find out how we can help your practice!