A Guide to Accurate Orthotics Billing
Numerous Medicare beneficiaries in the US are dependent on durable medical equipment supplies considering their health condition. These DMEs along with orthotics and prosthetics supplies are quite expensive, hence DME and orthotics billing require special attention to maintain the financial health of your practice.
DMEPOS are necessary to improve the quality of life and maintain independence of the patients. However, the regulatory intricacies in orthotics and DME billing make it difficult for your staff to maintain accuracy within the overall process. Thus, you develop a chance of potential revenue loss within the process.
Steps in DME and Orthotics Billing
Medicare payment for most DMEPOS is based on fee schedule amount. Orthotics billing comes under Medicare Part B which covers 80% of the approved costs of custom-made or pre-made orthotics items.
The steps in precise billing for DME and orthotics are as follows-
The entire workflow starts with a prescription as applicable, before it is eligible for coverage
A typed CMS 1500 claim form is used for billing
Appropriate HCPCS level II codes along with applicable modifiers (including, but not limited to NU, RR) are incorporated within the bill
Bill maintenance and repair modifier codes
Use miscellaneous codes as applicable
You must provide a complete description of the item
With the initial claim consider submitting the factory invoice if required
Make sure there is medical necessity form with physician’s approval
Appropriate Codes for Orthotics Billing
Under section 1861(s)(9) of the Social Security Act orthotics are defined. These orthotics require minimal self-adjustment for appropriate use and do not require any specialized attention for bending, molding, trimming or customizing to fit the individual needs.
CPT codes for orthotics are used for orthotic evaluation, fabrication, selection and training.
97760- Orthotics management and training (including assessment and training), upper extremities, lower extremities, trunk, initial orthotics encounter; each for 15 minutes
97761- Prosthetics trainings, upper or lower extremities, initial prosthetics encounter; each for 15 minutes
97763- Orthotics and prosthetics management and training, upper end lower extremities, subsequent encounter; each 15 minutes
Off-the-shelf vs custom-fitted vs custom fabricated
Off-the-shelf and custom-fitted orthoses are those which are manufactured without a specific beneficiary in mind. An orthotic is considered prefabricated even if it is assembled in the clinic from prefabricated pieces.
On the other hand, custom-fabricated orthotics are developed from raw materials for a specific client.
You need to consider L codes for the items which are not fabricated on-site during orthotics billing process. The Medicare reimbursement for orthotics include-
Evaluation
Measurement and fitting
Fabrication and customization
Materials
Cost of labor
Delivery
For example,
HCPCS L3000- Foot, removable insert, molded to patient model
HCPCS L3030- Foot, removable insert, molded to patient’s each foot
Exception L Codes
When you consider appropriate coding for accurate orthotics billing you must remember the following-
A static/dynamic ankle foot orthosis (L4396, L4397) and replacement interface (L4392) are denied by Medicare when they are solely used as a prevention of a heel pressure ulcer
A foot drop splint/ recumbent positioning device (L4398) and replacement interface (L4394) are denied as they work as a measure against pressure ulcers
Socks (L2840, L2850) used in conjunction with other orthoses are denied by Medicare
There are also other factors to consider. Right foot and left foot orthotics should be billed on separate claim forms with appropriate RT and LT modifiers.
Final Thoughts
Accurate orthotics billing requires precision and detailed understanding. The DMEPOS regulatory norms make the coding and billing for orthotics more difficult. On the other hand, efficient billing workflow is necessary to maintain the financial health of the practice while ensuring quality care for the patients. Understanding coding caveats is the most intricate part within the billing process. Minor errors in coding and billing process are a major reason for increasing claim denials, and a higher frequency of the same will result in negative revenue. However, as you are aware of the situation, just like most of the providers you can consider outsourcing medical billing and coding services. Strategic outsourcing of orthotics billing activities from specialized revenue cycle management organizations like Sunknowledge can work wonders in drastically bringing down the operational costs. Additionally, you will have the best-inindustry practices as these experts have a detailed knowledge and understanding of the overall billing process. A dedicated professional assistant like Sunknowledge expert can further improve the overall revenue cycle, particularly the rate of collections. With an expert partner, there will be fewer errors and more clean claim submission, which will be a natural advantage for your orthotics practice.
