Insurance billing codes and diagnosis codes, etc

[Guest guest]

Since insurance has messed up the billing again I though I would pass

along some helpful info. I'm trying to figure out the best place to

post this info on the site too.

mom to na

Medical Diagnosis codes

754.0 (plagiocephaly)

756.0 (craniosynostosis)

This is the main billing code.

HCPCS National Code, effective October 1, 2002

S1040 Cranial remolding orthosis, rigid, with soft interface

material, custom fabricated, includes fitting and adjustment(s)

This is from the Orthomerica website: Insurance companies and state

plans have different criteria for coverage depending on the type of

plan and premiums paid. All of these plans require extensive

documentation to process the claims including the prescription,

letter of medical necessity from the referring physician, proof that

repositioning techniques were not successful in correcting the

infant's head shape. Additional information, such as, specific

measurements and clinical photographs may also be required. You

should contact your insurance company prior to your first visit with

the orthotist for evaluation and/or casting/scanning for a cranial

remolding orthosis. Ask your insurance company if they cover DME

(Durable Medical Equipment) and/or cranial remolding orthoses.

Cranial remolding orthoses are custom molded devices and carry a

specific billing code of S1040 or an undifferentiated code of L1499

or E1399. If your insurance company says that it covers billing code

L0100, tell them that the L0100 code is for a protective helmet, not

a remolding orthosis. If your insurance company tells you

that " orthotics " are excluded in your policy, ask what type

of " orthotics " the policy refers to. Many insurance companies exclude

orthotics worn in the shoes to prevent a variety of foot problems and

inaccurately generalize the term to include cranial remolding and

other types of orthosis.

Insurance updates:

BCBS – MA covers S1040 effective 8/03

http://www.bcbsma.com/common/en_US/medical_policies/fs400.htm

Medi-Cal orthotic rates, guidelines, and coverage.

Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement

Rates Orthotics

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-

MTP/Part2/orthocd1_a04a06a08p00.doc

This section contains information about Orthotic and Prosthetic (O &

P) appliances and program coverage (California Code of Regulations,

[CCR], Title 22, Section 51315).

http://files.medi-cal.ca.gov/pubsdoco/publications/Masters-

MTP/Part2/ortho_a06p00.doc