Re: UHC - Those approved, and DME relationship

[Guest guest]

I would hope that they would change the way it is coded so that it is

covered. I would think CT would want to do everything they can to

help you.

Sue

> > >

> > > Paid 100% for us under DME even though it was out of network.

Dr

> > > Stilnicki did all our paperwork.

> > > Lorraine, mom to Mackenzie DOC grad.

[Guest guest]

Hi. Unfortunately, I called CT and they said they can't change the

code due to computer reasons. Hmm. Not sure I buy that. Oh

well...I'm going to keep trying.

Robin

> > > >

> > > > Paid 100% for us under DME even though it was out of

network.

> Dr

> > > > Stilnicki did all our paperwork.

> > > > Lorraine, mom to Mackenzie DOC grad.

[Guest guest]

Hi,

I don't know if this will be helpful, but we have a link here at the

group site in the links/insurance/insurance help folder that tells

how the establishment of the S1040 code came about. As far as I can

tell from web searches, S1040 is an HCPCS Durable Medical Equipment

Code. It's a bit difficult to navigate through the link, so I'll

post the article here. It appears the industry pushed to have a

unique code set up so that cranial orthoses wouldn't be subjected to

the far lower reimbursement, as well as the totally different

clinical usage, of protective helmets in particular, or be lumped in

with miscelaneous orthotics:

>>>-O & P Business News reviews the historical and latest developments

on the regulatory front to help the O & P professional navigate

through the coding and reimbursement maze for cranial remolding

orthoses.

By Bill Gustavson

Throughout the years, there has been a lot of confusion regarding

how to code and bill for cranial remolding orthoses. The purpose of

this article is to review the historical and latest developments on

the regulatory front to help the O & P professional navigate through

the coding and reimbursement maze for cranial remolding orthoses.

Orthotists and prosthetists have treated children with positional

plagiocephaly since the 1970s. Dr. Sterlin K. Clarren, Dr. D.W

and Dr. J.W. Hanson wrote the first article about the use of cranial

remolding orthoses to treat positional plagiocephaly in 1979 in a

study done at the University of Washington. In 1998, the U.S Food

and Drug Administration (FDA) ruled that cranial remolding orthoses

fell into the category of class II medical devices. These devices

require strict control standards which include specific manufacturer

procedures, controls documenting skin biocompatibility, labeling

instructions, clinical/caregiver instructions, etc. In order to

continue providing these orthoses, companies had to apply for and

receive FDA 510(k) clearance, which is an expensive and labor

intensive process. As a result of these changes, many orthotists and

prosthetists stopped providing cranial remolding orthoses because

their design had not gone through the process of being cleared by

the FDA.

Introduction of L-Codes

When the L-codes were developed in the late 1970s, there were two L-

codes developed for cranial helmets:

L0100 – cervical, craniostenosis, helmet, molded to patient model

L0110 – cervical, craniostenosis, helmet, non-molded

These L-codes were originally created for protective helmets — not

cranial remolding orthoses. Protective helmets are not dynamic in

function and are not intended to remold the infant's skull while the

head is actively growing. Unlike many remolding designs, protective

helmets encompass the entire skull and serve to protect adults and

children from banging their heads or to cover an open area of the

cranium secondary to trauma or surgery. Protective helmets require

minimal clinical treatment time and cost significantly less than

cranial remolding orthoses. The primary function of cranial

remolding orthoses is to correct and remold the abnormal head shape

of the skull toward greater symmetry. These orthoses are very

service-intensive and require follow-up visits during a three- to

six-month treatment program.

In July 2000, Orthomerica received 510(k) clearance from the FDA to

market and manufacture the STARbandÔ cranial remolding orthosis to

credentialed orthotists and prosthetists. Since there was no code

available to address these types of orthoses, Orthomerica submitted

an application to the HCPCS Alpha Numeric Panel in March 2001.

Orthomerica received a response from the HCPCS Panel in October 2001

stating that they changed the existing nomenclature on HCPCS codes

L0100 and L0110 to the following, effective Jan. 1, 2002:

L0100 - cranial orthosis (helmet), with or without soft interface,

molded to patient model

L0110 - cranial orthosis (helmet), with or without soft interface,

non-molded

However, no changes were made to the fee schedule for these codes.

As noted in his column in the Feb. 15th issue of O & P

Business News, the government's hands are tied when working with O & P

industry experts regarding policy decisions under the Federal

Advisory Committee Act (FACA). One of the major challenges of FACA

is that it puts the responsibility on both the manufacturers and the

providers to challenge these decisions prior to implementing new

policies and fee schedules. Unfortunately, these challenges require

a significant investment of human and financial resources from all

parties involved.

Grass Roots Campaign

In October 2001, Orthomerica started a grass roots campaign to

acquire a unique billing code for remolding orthoses among

physicians, orthotists experienced in treating children with cranial

remolding orthoses, and other O & P providers and manufacturers with

FDA cleared designs. Orthomerica engaged a regulatory attorney and

initiated a letter writing campaign to all Medicare intermediaries

including CMS, the SADMERC and DMERCs. Fortunately, the campaign

paid off and the HCPCS Alpha Numeric Panel issued a new code in

October 2002. Since cranial remolding orthoses are limited to

infants, the panel did not assign an L-code to these types of

orthoses. Instead, they assigned an S-code, which is also a HCPCS

level II code. The descriptor of this code is as follows:

S1040 – cranial remolding orthosis, rigid, with soft interface

material, custom fabricated (includes fitting and adjustment)

There is no assigned reimbursement for the S1040 code because

Medicaid and private insurance companies, not Medicare, recognize

these types of orthotic devices for infants. As a result, it is up

to each insurance company and state Medicaid programs to establish

coverage and reimbursement for cranial remolding orthoses billed

under this code

..

The HCPCS Panel sends coding information to state Medicaid programs

and private insurance companies on a quarterly basis. Unfortunately,

it takes time for these carriers to implement new codes such as the

S1040. The great news is that many insurance companies are now

starting to recognize the S1040 and establish a reasonable fee

schedule for these service-intensive orthoses.

In the interim, cranial providers and state O & P associations will

have to be diligent in educating insurance companies and state

Medicaid programs about cranial remolding orthoses billed under

S1040 to substantiate coverage and adequate reimbursement. Once

implemented, this new code should help expedite claims processing

and eliminate problems previously associated with billing not-

otherwise-specified codes for this time-critical orthotic treatment

program. If an insurance company has not received notification about

S1040, this information can be found on the Centers for Medicare and

Medicaid Services Web site at

www.cms.hhs.gov/medicare/hcpcs/hcpctmp.pdf (PDF file format).

Policy Challenges

The O & P profession is facing significant challenges in terms of

policy changes that impact new technologies, Medicare coverage and

reimbursement. To their credit, the Medicare intermediaries have

responded favorably and quickly to proposed changes in cranial and

spinal policies throughout the years.

However, these changes come with a significant price tag. During the

past three years, Orthomerica alone has spent more than $300,000 in

regulatory attorney fees challenging these new policies on behalf of

the industry. While Orthomerica will continue to closely monitor and

respond to adverse regulatory changes, it is critical that the O & P

profession becomes more proactive by responding to policies that may

have a profound impact on our future.<<<<

Also, here is a pertinent question and answer from the Orthomerica

website:

>>>Will my insurance cover Orthomerica's cranial remolding orthoses?

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 orthoses.<<<

I saw another post a while back from a group member that posted to

ensure that the insurance carrier properly cross-referenced the old

misc. code of E1399 to the proper specific code of S1040, and that

helped her appeal out.

These insurance issues seem to be horrific to navigate, so I applaud

all your efforts to get coverage!

Take care,

Christie (Mom to Repo'd Remy)

-- In Plagiocephaly , " rjsnobbin " <robincollins@v...>

wrote:

>

> Hi. Unfortunately, I called CT and they said they can't change the

> code due to computer reasons. Hmm. Not sure I buy that. Oh

> well...I'm going to keep trying.

>

> Robin

>

>

> > > > >

> > > > > Paid 100% for us under DME even though it was out of

> network.

> > Dr

> > > > > Stilnicki did all our paperwork.

> > > > > Lorraine, mom to Mackenzie DOC grad.

[Guest guest]

I was told that UHC paid our claim because her Plagio was documented

at birth and it was severe and not considered cosmetic. I think it

get paid depending on how the claim is filed with the supporting Dr

notes. I dident do anything special to get our claim paid except when

they first denied because it was out of network I asked who was in

network for a DOC band and was told no one so they sent the check.

Lorraine.

> > >

> > > Paid 100% for us under DME even though it was out of network.

Dr

> > > Stilnicki did all our paperwork.

> > > Lorraine, mom to Mackenzie DOC grad.