Frequently Asked Questions and Answers about Orthotics Billing

Frequently Asked Questions and Answers about Orthotics Billing Orthotics is a solution for a range of conditions affecting the foot -- plantar fasciitis, hammertoes and bunions.

Here is an FAQ on orthotics billing.

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Regular, repetitive stress on the feet on a day-to-day basis can cause the connective tissues to lengthen, which can result in the gradual breakdown of the natural support for the bones and joints of the feet. This can lead to a sagging of the foot’s arch causing severe back, neck and knee pain. Preventing the occurrence of back pain, knee pain or spinal joint degeneration requires additional support and shock absorption capacity and this is where orthotics becomes relevant. Foot orthotics ensures overall health of the body joints through effective alignment of the feet with the spine. Podiatrists and other pain management specialists often deal with physically active individuals suffering from pain in the joints and fatigue as a result of improper foot alignment. If there are conditions that involve tendons, bones, muscles, and ligaments not functioning optimally and causing pain and discomfort, then foot orthotics could be the ideal solution. Choosing the right orthotic device obviously depends on your diagnosis and what your specific needs are. Podiatry billing services are available to help podiatrists report orthotic treatments in their medical claims.

Foot orthotics refers to insoles that provide cushioning and minor support in your shoes.

Typically, worn within shoes, these orthotic insoles are intended to support or correct the abnormal or irregular walking pattern. Orthotic insoles come in different types and are made from various types of materials. There are semi-rigid and rigid orthotics, as well as semi-flexible orthotic soles. Let’s discuss some of the frequently asked questions and answers about orthotics and billing – Q: Why are orthotic devices recommended by podiatrists?

A: Podiatrists generally recommend orthotic devices for several reasons, including 

Aligning and supporting the foot or ankle

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Preventing, correcting or accommodating foot deformities

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Improving the overall function of the foot or ankle

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Reducing the risks for further injuries

In most cases, podiatrists may recommend an orthotic device if other treatments, such as exercises, have not proven effective.

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Q: What foot conditions are orthotics used to treat?

A: Podiatrists may prescribe orthotics to treat a number of problems relating to the foot and the ankle. These foot problems include – bunions, flat feet, hammer toes, heel spur, plantar fasciitis, high arches, shin splits, Achilles tendonitis, injuries, bursitis, back pain and arthritis.

Q: Does Medicare offer coverage for Orthotics?

A: Yes, Medicare offers coverage for orthotics under the durable medical equipment (DME) benefit. Medicare considers durable medical equipment (DME) to be equipment used for medical reasons in the home, to have a life expectancy of more than 3 years, and not to be useful to anyone not sick or injured.

Medicare lists the following devices as orthotics under the heading of DME 

Ankle, foot and knee bracing

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Prosthetic devices such as artificial limbs and eyes

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Orthopedic shoes when they’re a necessary part of a leg brace

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Hand, wrist and elbow bracing

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Back, neck and spinal bracing

Q: What are the eligibility requirements for receiving Medicare coverage?

A: In order for Medicare to cover orthotics, patients must meet the following eligibility criteria – 

The healthcare provider must determine that the orthotics are medically necessary and must prescribe it as a part of complete treatment plan.

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The orthotic shoes and inserts must be prescribed by a podiatrist or other qualified doctor such as an orthotist, prosthetist, pedorthist or other qualified individual.

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The DME supplier of the orthotic must be enrolled in Medicare and accept Medicare assignment.

Q: What are included in the Medicare reimbursement for Orthotics?

A: For orthotics, Medicare reimbursement includes -

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

evaluation

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measurement and/or fitting

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fabrication and customization

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materials

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cost of labor

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delivery

Q: What amount of coverage will Medicare pay?

A: Medicare Part B will typically pay 80 percent of the approved cost for orthotics equipment.

Patients need to pay the remaining 20 percent Medicare Part B coinsurance out-of-pocket (after their annual Part B deductible is met). In 2019, the yearly Part B deductible is $185.00.

Orthotic costs may depend on the type of orthotic device you need (whether the orthotic is prefabricated or custom-made. But, it is important for patients to consult their physician or orthotic specialist to determine what type of equipment is right for them. In addition, patients should know that Medicare occasionally values the equipment at less than the actual purchase price, which means that they will be responsible for paying the difference in amount.

However, even after consultation with the physician or podiatrists, patients determine that Medicare’s Part B coverage does not meet their specific orthotic needs; they may opt for Medicare Part C coverage (sometimes called a Medicare Advantage Plan). Part C coverage usually includes extra services when compared to Part B coverage, which may help to balance the cost of various orthotic devices. Co-payments for Part C may differ from those of Part B, therefore be sure to discuss your individual needs with the doctor and a Medicare specialist.

Q: What are the CPT codes to bill for orthotics?

A: With detailed and specific codes, podiatry coding is a challenging process. Any mistake in selecting codes can lead to claim denials and thus reimbursement issues. The key to billing for orthotics lies in correct verification of the patient's insurance coverage for durable medical equipment (DME). The CPT codes used for reporting orthotic and prosthetic management and training services were revised by differentiating between initial and subsequent encounters.

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CPT codes 

97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.

(CPT code 97760 - the fitting of the functional orthotics, training in use, care and wearing time of the functional orthotics and brief instructions in exercises while the functional orthotics are in place. Specifically, this code refers to the initial encounter). 

97761 - Prosthetic(s) training, upper and/or lower extremity (ies), initial prosthetic(s) encounter, each 15 minutes.

(Healthcare providers need to use this CPT code for any prosthetics-related instructions or interventions, including - ADLs for UE and LE amputees, donning and doffing activities, walking for LE amputees, residual limb management, and prosthesis-related self care. This code applies only to the initial encounter). 

97763 - Orthotic(s)/prosthetic(s) management and/or training, upper extremity (ies), lower extremity (ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes.

(Providers must use CPT codes 97760 and 97761 only for initial encounters. CPT code 97763 includes the same activities described by the other two codes, but is specifically reserved for subsequent encounters for modifications, fitting adjustments, and additional training regardless of whether the orthotic is custom made or prefabricated).

Q: What are L-codes for orthotics?

A: L-codes are the HCPCS codes providers must use when billing for splints, braces, and any other services related to assessment, fabrication, and supplies—including follow-up. 

L3000 - Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

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L3001 - Foot, insert, removable, molded to patient model, Spenco, each

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L3002 - Foot, insert, removable, molded to patient model, Plastazote or equal, each

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L3003 - Foot, insert, removable, molded to patient model, silicone gel, each

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L3010 - Foot, insert, removable, molded to patient model, longitudinal arch support, each

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L3020 - Foot insert, molded to patient model, longitudinal/metatarsal support, each

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L3030 - Foot insert, removable, formed to patient foot, each

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L3031 - Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each

Q: When are Orthotics not considered medically necessary?

A: Orthotics are considered to be not medically necessary under the following circumstances – 

Orthotics that are not prescribed by a qualified physician

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Spring-loaded orthotics and static progressive stretch devices

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Custom-made orthotic devices are not medically necessary unless there is clinical documentation (that indicates a non-custom made orthotic device is not appropriate for the condition or diagnosis)

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Orthotic devices for sport-related activities

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Orthopedic shoes (unless one or both shoes are an integral part of a leg brace)

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Upgraded splints or orthotics

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Elastic stockings and garter belts

As you get older, you need to pay more attention to the health of your feet and ankles. Ignoring problems related to the feet and ankles can affect mobility and prevent you from carrying out even routine tasks. When the feet are not properly supported, movement can cause stress and strain. Eventually, that stress may result in greater bone instability, thus leading to overpronation, fallen arches and back and knee pain. Additional support and shock absorption provided by orthotics can help prevent hip, knee or spinal joint degeneration. Orthotic devices support the foot or ankle, preventing, correcting or accommodating foot deformities and improving the overall function of the foot or ankle.

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