11/01/2016
Billing L4360 vs L4361
We are having difficulty when billing L4360 vs L4361. We typically alter the CAM Walker in some manner justifying billing the L4360. We had Medicare DME and other Medicare replacement insurances request proof of delivery along with other records. In the past, we used the paper the patient signed indicating receipt of the item and it's warranty information. This had been denied as sufficient POD. We then started using the label (indicating L4361) from the item as POD. The claim was then either denied or retracted as billed incorrectly - because we billed L4360 but label indicated L4361. Has anyone else has had this trouble and what resolution would you recommend?
DME and Medicare advantage plans are denying or retracting payment for the item due to submission of incomplete documentation to justify medical necessity and proof of delivery. In order to meet medical necessity requirements, the following must be submitted (if requested by the insurance) to justify billing- note that L4360 as a custom item will require additional documentation compared to L4361, which is pre-fabricated and does not require any modifications (from Noridian's website):
- Treating physician's dispensing and written order
- Dispensing order (if item is dispensed based on a dispensing order)
- Patient's medical records (physician medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that may support the item(s) provided are reasonable and necessary
- Justification to support the custom fitted or off the shelf orthosis code billed (if applicable)
- Documentation to support the medical necessity of custom fabricated rather than prefabricated orthosis (if applicable)
- Proof of delivery
- The Advanced Beneficiary Notice (if applicable)
- Any other supporting documentation
You may not use a different code to bill and show proof of delivery of another code. When the patient signs the acknowledgement of receipt, it should state the code you are billing the carrier with, in addition, to the invoice from manufacturer of the cam walker purchased.
L4360: Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4361: Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf
Below is a link to Noridian for your reference and additional information: