Medicare Services Denied

WE just received a statement from Medicare demanding their money back because a patient was in a Skilled Nursing Facility at the time of service. I looked up the charges and it was for receiving Diabetic Shoes (DME)- codes A5500 and A5512) . I asked the other coders here and looked at the dictation for the past visits and nothing states she was at a facility, or that she had moved. My boss wants me to re-bill but it sounds like Medicare thinks the SNF should pay for it. I cant find anything on the CMS/Medicare websites that help us at all. Should I set it to patient responsibility or re-bill with new modifiers/facility codes?

re: Medicare Services Denied

Something to consider, when billing orthotics, be sure to verify with your payer, but CMS requires a supplier to bill with the Place of Service (POS) 12, “Home” even when they are delivered to a Nursing facility.

Be sure you have your KX modifier on the claim as well as other documentation and receiving information. Remember you can only bill once the product has been delivered to the patient and signed for, the DOS is the date the product was received and fitted.

Be sure you have a payable diagnosis code, keep all documentation, orders, visits and packing slip on file. The KX modifier ensures you as the DME supplier, can provide everything required and have it available if requested by CMS.

There is a lot to consider when supplying orthotics and shoes. Find-A-Code has information on Documentation and rules and guidelines. However, I would suggest to start with your Medicare carrier and look up the LCD’s for your location, There is also a tool called Check-A-List used by Find-A-Code customers, it is a checklist for Ankle-Foot/Knee-Ankle-Foot Orthosis, available in Find-A-Code under Tools.