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Billing for Orthotic Therapy

Billing for orthotic therapy is as diverse a process as any in clinical health care. There are not recognized evaluation procedures, definitions or applications for the modality, let alone adequate published validation for its efficacy. Adding insult to aggravation, third party payers do not adequately differentiate custom orthotic devices from other “supportive” devices, be they custom, customized, prefabricated, sized to imprint, fit to size, direct or indirect thermo-molded.

Third party payers have a vested interest in distinguishing between medical necessity and non-covered care given for medical reasons. Their reimbursement for durable medical equipment and “over-the-counter” applications is dramatically different. It is recommended you provide them with easily perceived justification (letter of medical necessity) along with every claim submitted.

 

Impression Casting

Clinicians will routinely bill for making impression casts (molds) under CPT Code: 29799, which is an unlisted casting code. This may be best described as a method for capturing an accurate impression, sufficient for modeling specific anatomical segments. The impression is used directly for fabricating orthotic devices.

CPT 29799 is billed as a single line item, with one unit value. It can be defined as bilateral, since it is an unlisted code.

 

Letters of Medical Necessity

Keep it simple is the best advice offered here, complex dissertations with intricate nuances about the engineering marvel of an orthotic is over kill and will probably be overlooked.

Text in a letter of medical necessity should be patient specific and above all brief. Avoid generic pre-printed letters.

Biomechanical Services provides example letters of medical necessity and commonly used text descriptions of processes. These example letters are available by calling the laboratory and speaking with someone in Customer Service.

Keep in mind, if orthotic devices are not a covered benefit under the patient's insurance plan, they are not a covered service. Sending a letter of medical necessity will not likely change that.

 

Line Item Billing

HCPCS, L-Section codes used for billing orthotic devices are more specific to “each”, where “pair” does not translate. This means a left and right device should be billed as separate line items. Making the mistake of billing for a pair will result in getting paid for one orthotic device. Changing the unit value to two (2) is does not assure sufficient reimbursement either, as payers will commonly overlook such details. HCPCS code modifiers for Right and Left are ” –RT” and “–LT”, respectively.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required adoption of standards for coding systems that are used for reporting health care transactions. Third-party payers, and most commonly health insurance programs, now require health care providers to use specific assigned codes on their claims for payment, including prescription foot orthoses.

Listed below are commonly utilized billing codes for custom orthotic devices made according to prescriptive application on individual patients, along with brief descriptions regarding their specific usage:

L3000
Foot insert, removable, molded to patient model. "UCB" Type Berkeley Shell, each. Plastic device, molded over model of patient's foot to provide control of the foot.

Used most commonly for prescription foot orthoses made of rigid or semi-rigid plastics. The key component is “to provide control”. Improving foot function by controlling specific segments or events is achievable by modifying a three dimensional patient model and utilizing materials sufficiently rigid enough to maintain those modified contours under a patient's individual body weight.

This code is also used for UCBL devices, Modified UCB devices and all other rigid or semi-rigid type Foot Orthoses. Typical modifications may include changes in heel seat depth, medial or lateral flanges and other alterations to trim lines. Additional component modifications such as biasing forefoot or rearfoot positions, supplemental padding, top covers, accommodations for lesions or structural anomalies, and other additions may also be applied.

L3010
Foot insert, removable, molded to patient model, longitudinal and metatarsal support, each. A soft, semi-flexible, or rigid device molded over a model of the patient's foot and placed in the shoe to provide support under the longitudinal arch of the foot.

Used commonly for custom prescriptive application of rubber, steel, leather or plastic used to support the foot, made from a model where no corrections or modifications to foot segments are applied. Only longitudinal arch “support” is supplied and no attempt to “control” function is attempted.

Support type devices offer only longitudinal and metatarsal contours, have trim lines limited to the plantar area of the foot, indistinguishable heel cupping, and make no attempt to bias or otherwise control foot function.

L3020
Foot insert, molded to patient model, longitudinal and metatarsal support, each. A device molded over a model of the patient's foot and placed in the shoe to provide support under the ball of the foot.

Used commonly for custom prescriptive application of rubber, steel, leather or plastic used to support the foot, made from a model where no corrections or modifications to foot segments are applied. Longitudinal and metatarsal “support” is supplied along with additional support to accommodate or alleviate the “ball of the foot”. No attempt to “control” function is attempted.

 

Bill for the Orthotics at Dispensing

Bill for orthotic therapy at the time of dispensing, third party payers are very uncooperative about paying for services before they are dispensed. This will put the clinic in a position of having to pay our laboratory bill before receiving reimbursement. While this is patently unfair and fiscally disadvantageous, it is an unfortunate fact when doing business with insurance companies.

 

Deposits

It is highly recommended your clinic receive a deposit for their orthotic therapy at the time of casting. Experience shows us that someone vested in their health care tends to follow through on provisions for their own success.

Patients should be prepared for their deposit obligation when presented with your decision to pursue therapy. Your policy for collecting deposits can vary from charging the entire case fee to getting a percentage that is refunded after reimbursement is received. In any case, the deposit should be of an amount that at least covers your supplies and estimated laboratory bill. We suggest you never incur the cost of initiating therapy you may not be paid for, were the patient to disappear.

We also recommend the patient receive a printed form outlining your policy, what they can expect in the way of financial obligation and a place to sign on to your prescribed plan. This insures in advance you have matched your expectations with those of the patient.


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