What You Should Know About Billing For Orthotics
- Volume 17 - Issue 6 - June 2004
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Doc Baker had it easy. As the only physician in Walnut Grove, he had the market cornered. Anyone who lived in or visited the fictional center of the Little House On The Prairie television series (whether it was Laura Ingalls, Nellie Olsen or some unfortunate guest star like Ernest Borgnine) had to go to Doc Baker for their ills. Everything was curable and everyone paid at the end of the visit.
If Walnut Grove existed today, it would likely have a variety of specialists (including a couple of podiatrists) and there would be an insurance agency (or a dozen) processing claims and gradually doling out reimbursements. Doc Baker would have a billing specialist in his office and he would indeed need to know that if he wanted to bill for a molded removable foot insert, he would need to use L3010 to code the need rather than L3000.
One of the reasons one hearkens back to simpler times is because it is so difficult to distinguish between CPTs and L codes, and what Company A will pay for that Company B will not, etc. As is the case with most anything, billing for orthotics requires taking a step back to gain some perspective over what to do, how to do it and when.
Truth be told, you are not absolutely required to accept any third-party insurance plan. You could conceivably run a cash-only practice. Of course, doing so would mean turning down 99 percent of the potential business that could be yours. So you do accept these plans (albeit grudgingly) and in doing so, you also must put up with their rules, codes, schedules and other eccentricities.
Emphasize A Strong Awareness Of Insurers’ Conditions, Exclusions And Other Eccentricities
These rules, codes, schedules and eccentricities are at the heart of what you cannot determine or control, but are things you must be aware of nevertheless. These factors include the following:
The policy’s rules. Many insurance policies have exclusions—nuanced exclusions—regarding reimbursement and it is the responsibility of each participating practice to know those exclusions, and deal with patients and billing accordingly. It also behooves the practice to make certain its patient records are current with regard to what insurance each patient currently uses.
Conditionals. Even insurance companies that do reimburse for orthotics put limits or conditions on what they will and will not pay for. For example, companies may limit the number of orthotics devices that they will pay for in a given year. They might only pay for lab work or fabrication done in specific laboratories. They might also restrict what codes can be used for billing purposes.
Exclusions. Some policies exclude certain orthoses. For example, spring-loaded orthotics (like dynasplints) often have restrictions attached to their purchase. Elastic stockings are likewise often ineligible for coverage. In these cases, the patient would be responsible for the full cost of the prescribed treatment. There are also cases in which it is acceptable to obtain a refundable deposit from the patient for a treatment if it is both listed in your office policies and communicated to the patient before he or she walks into the treatment room.
"Medical necessity”and other rules. Some of the more heated arguments between DPMs and insurance companies have come over the determination of medical necessity. Even if you take the most appropriate approach to diagnosing a patient’s ailment and prescribe a treatment solution that is completely within the realm of the necessary and no more, it may not matter to frugal insurance companies. Chances are, you will often find yourself or your staff locked in debate with insurance companies that have their own idea of what is and is not acceptable medicine.