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   Medicare Billing

Innovate, Inc. is a distribution company that offers Medicare approved products.  This page outlines the Medical necessity, HCPCS Codes, and Diagnostic Codes associated with each product line.

Medicare Billing Process

The process of selling, delivering, training, billing, and collecting reimbursements for the Cybertech Back Braces, Dr Zen Diabetic Shoes, and Encore ED Vacuum Devices follow a similar process as with most DME products.  Below, we take you through each of the steps along with estimates for billing and reimbursements.
 

Common Requirements

All of these products must meet some of the same criteria including:

  • Medical Necessity qualification
  • Eligibility and Medicare Part B or Insurance qualification
  • Rx Signed by appropriate physician
  • Delivery confirmation
  • Documentation approval by patient

 
  Back Braces

   Certification & Training

For Medicare Provider companies, the certification requirements vary from state to state.  It is recommended that Medicare Providers who would like to provide back braces, contact their Accreditation company to determine the certification requirements. Innovate, Inc. provides personalized telephone training, resulting in a Training Certificate. 


   Who Qualifies

One of the following indications must be met:
●  To reduce pain by restricting mobility of the trunk; or
●  To facilitate healing following an injury to the spine or related soft tissues; or
●  To facilitate healing following a surgical procedure on the spine or related soft tissue; or
●  To otherwise support weak spinal muscles and/or a deformed spine.

 

   Diagnostic Codes

Diagnosis 

Description

724.2
724.0
728.87
756.12
722.10
721.3
847.2
724.9
722.52
 

Lumbago
Spinal Stenosis
Muscle Weakness
Spondylolisthesis
Lumbar Disc Displacement
Lumbosacral Spondylosis
Lumbar Strains/Sprain
Spinal Disorder
Lumbar/Lumbosacral Intervertebral Disc Degeneration
 

   Items Qualified for

If a patient is qualified, they may receive the following items:

  • The Rx sent to the Physician should provide the options of different back braces.  It is the responsibility of the Dr. to determine the appropriate back brace for their patient.
  • 1 Cybertech Back Brace - Includes Brace & Appropriate Panels (1 unit every 5 years)
   Reimbursement Analysis

 

Medicare

Medicare

Average

Average

Average

 

Allowable

Average

Medicare

Dealer

Medicare

Description

HCPCS

Range

Allowable

Reimb.

Cost

Margin

           

Spine Brace Flex Power Plus w/Panels

L0627

$333 - $443

$388

$310

$105

$205

           

Premium Plus w/Panels

L0631

$831 - $1,107

$969

$775

$210

$565

           

Tri-Mod w/Frame & Panel

L0637

$949 - $1,266

$1,107

$886

$210

$676


  Knee Braces

   Certification & Training

For Medicare Provider companies, the certification requirements vary from state to state.  It is recommended that Medicare Providers who would like to provide knee braces, contact their Accreditation company to determine the certification requirements. Innovate, Inc. provides personalized telephone training. 


   Who Qualifies

One of the following indications must be met:
●  To reduce pain by restricting mobility of the knee; or
●  To facilitate lateral or medial compartmental arthritis; or
●  To facilitate healing following a surgical procedure on the knee or related soft tissue; or
●  To otherwise support instability of knee joint.

 

   Diagnostic Codes

Diagnosis 

Description

714.0
715.16
715.26
 

Rheumatoid Arthritis
Osteoarthritis - Primary Lower Leg
Osteoarthritis - Secondary Lower Leg
 

   Items Qualified for

If a patient is qualified, they may receive the following items:

  • The Rx sent to the Physician should provide the options of different knee braces.  It is the responsibility of the Dr. to determine the appropriate brace for their patient.
  • 1 Knee Brace - Includes Brace & Adjustment hinges (1 unit every 5 years)
 

 
  Dr Zen Diabetic Shoes

   Certification & Training

There are specific Medicare education and certification qualifications required to provide diabetic shoes.  In most of the states the only requirement is to have a Manufacturers Certificate.  Innovate, Inc. sells a Fitter Training course that results in a Dr Zen Manufacturer Certificate.  The other states (FL, AR, OH, IL, OK, TX, etc) may require the fitter to be a Pedorthist - these states will not accept a Manufacturers certificate.  If you are considering providing shoes, contact your Accreditation company to determine the certification requirements.

Manufacturer Certificate

Innovate, Inc. offers a Self-study Fitter Training course that can be sent via Email along with a short test.  The entire program takes less than 6 hours to complete.  Upon successful submission of the test, a Dr Zen Manufacturers Certificate will be issued that can be used for those states that will accept it.  Call your Accreditation company to determine if the manufacturer certificate will satisfy your State requirement.


   Who Qualifies

The following criteria must be met:
●  The patient has diabetes mellitus (ICD-9 diagnosis codes 250.00-250.93), is eligible for Medicare benefits; and

The patient has one of the following conditions:
● 
Previous amputation of the other foot, or part of either foot, or
● 
History of previous foot ulceration of either foot,, or
● 
Previous amputation of the other foot, or part of either foot, or
●  History of pre-ulcerative calluses of either foot, or
●  Peripheral neuropathy with evidence of callus formation of either foot or
●  Foot deformity of either foot or
●  Poor circulation in either foot
 

   Diagnostic Codes

Diagnosis 

Description

250.00
250.01
250.02
250.03
 

Diabetes mellitus without mention of complication
Diabetes mellitus without complication type i not stated as uncontrolled
Diabetes mellitus without complication type ii or unspecified type uncontrolled
Diabetes mellitus without complication type i uncontrolled
 

   Items Qualified for

If a patient is qualified, they may receive the following items:

  • One Pair of Therapeutic Shoes
  • Three Pairs of Custom or Pre-Fabricated Inserts (Per Calendar Year)
   Reimbursement Analysis
 

Description

HCPCS

Qty 

Unit Billed

Amount

         

Therapeutic Shoes

A5500

2

$66.76

$133

         

Custom Inserts

A5513

6

$40.65

$244

         

Total Billed

     

$377

         

Medicare Reimburse @ 80%

     

$301

         

Average Cost

     

$131

         

Medicare Margin

     

$170

         

Other 20% Margin

     

    $76

         

Total Potential Margin

     

$246

 

 

 
  VitalWear Systems

   Certification & Training

Medicare does not require any education or certification to provide these products.  As of April 1, 2011, Medicare declassified the code (E0217) for this product line and NO longer reimburse for it.

Most Private Insurance companies are continuing to reimburse for this product line for workmen's compensation and personal injury protection needs.


   Who Qualifies

The following indication must be met:
●  To relieve pain and improve circulation
 

   Diagnostic Codes

Diagnosis 

Description

714.00
714.89
715.90
728.85
721.30
721.90
724.30
782.30
459.80
 

Rheumatoid Arthritis
Inflamm Polyarthrop-NEC
Osteoarthrosis NOS - Unspec
Muscle Spasm
Lumbosacral Spondylosis
Spondylosis NOS w/o Myelop
Sciatica
Edema
Poor Circulation
 

   Items Qualified for

If a patient is qualified, they may receive the following items:

  • VITALWEAR System - Includes System and 1 Wrap (1 unit every 5 years)
   Reimbursement Analysis
    Amount  
Description HCPCS Qty Billed Range  
       
VITALWEAR System & 1 Wrap E0217 1 $443 - $521  
       
Medicare Reimburse @ 80%     $354 - $416  


 
 
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