What You Should Know About Billing For Orthotics
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. Trying To Achieve A Painless Claim Doing everything you can to avoid such battles is essential. Prolonged bouts of billing code fisticuffs only lengthen the time in which all sides get paid or receive their service. Of course, this requires practices to be consistent in a situation in which not much consistency exists and it requires them to be specific where specificity is difficult. To this end, it’s important to get your references and supporting literature together so you can tell between what you should have and what you do have on your EOB. Key resources for finding insurance codes include the Healthcare Common Procedure Coding System (HCPCS) book and its quarterly updates as well as the AMA’s Current Procedural Terminology (CPT) book. One must also be aware of all current billing guidelines—Medicaid and otherwise—for your state and local area. Lack of adherence could cause excessive time delays in getting reimbursement. Be sure to bill in pairs when appropriate. The founding fathers of the HCPCS guidelines were not podiatrists. Foot orthotic codes are defined as single devices although they are usually dispensed to patients in pairs. Be sure to code and bill right-foot and left-foot orthotics on separate claim form lines with the appropriate code, modified with “-RT” and “-LT.” Keep an open dialogue with your provider in case you find the codes provided for you to use are insufficient for the description of orthotic work done for the patient. Do not just assume a catch-all or unlisted code (such as the CPT 29799—unlisted casting code) is correct; double-check with the provider to make sure you’re submitting the right thing properly. If you submit a letter of explanation or pre-authorization to a provider, make sure each is accurate and to the point, pertaining exclusively to the needs of the patient. In other words, form letters are highly discouraged. Scrutinizing EOBs And Dealing With Denials When you receive your Explanation of Benefits (EOB) form, make sure you or your office’s billing guru goes over it carefully. In order to ensure that the insurance company has done its job properly and that are receiving the maximum amount of reimbursement, keep an eye out for the following things. Do your totals and line items match? The first thing to look for on the EOB is the totals billed and compare them to the health insurance claim form you submitted on your patient’s behalf. If the totals do not match, you’ll know right off the bat that something else within the form is missing. Check the line items, which display each procedure performed, to make sure there are no items “bundled” or duplicated. In some instances, rule changes or new laws will cause some codes to be bundled and some procedures are designated “separate procedures.” In either case, be as certain as possible that all pertinent codes are assigned and that all pertinent federal and state guidelines have been followed. One must also be cognizant of any deductibles factored in by insurance companies in excess of what your patient is entitled. They might try to do this rather than pay the benefits quoted to you originally. You also might open the EOB to find that you have been reimbursed based on an incorrect (and lower-paying) policy or enrollment the insurance company “accidentally” put in place. Documenting these cases is very important since insurers are bound by law to pay the benefits they quote. Any proof you have that they have not paid would help bolster your case in a court of law. If the claim your office has submitted is denied, you should determine the reasons behind the denial. If the devices you prescribed are not covered by the insurer, communicate this to your patient and arrange for payment. However, you should have known the potential for this occurrence before you sent in the billing. If you billed using incorrect codes, send in a corrected claim form using the appropriate codes. If you must submit additional documentation to prove medical necessity, compile a report specific to the needs of the patient in question. Why You Should Encourage Refundable Deposits As you can imagine, there are other things to consider when billing for orthotics billing. As briefly mentioned above, it is not uncommon for practices to require patients to put down a refundable deposit for some forms of treatment in order to account for discrepancies or misalignments in payment schedule among various third parties. For example, you can typically expect the laboratory that produces orthotic fabrication of impression casts to get its bill to your practice’s door faster than you can get a claim out to an insurance payer. To avoid putting your practice’s accounts in arrears (or winding up shelling out for the orthotics yourself), obtain a refundable deposit from your patient a refundable deposit (usually for the cost of the lab work). The patient would then receive the appropriate refund of the deposit when the payer’s explanation of benefits arrives. When using this policy, make sure it is plainly stated in a form new patients have to fill out and sign prior to the visit. Also ensure that the policy is in your posted office policies and reinforced in your employee manuals. You may also want to communicate this verbally to the patient before beginning any casting work. Stay Informed Of Changes Among Third-Party Payers You should also make certain you and the others in your practice (particularly those who are part of your billing function) keep abreast of any changes that would affect how or if you bill third-party payers. Orthotic billing code manuals are published regularly. State and federal Medicaid legislation may alter guidelines as you currently know them. Medical procedures or orthoses once covered with little or no question might now be covered with many and varied questions, or not covered altogether. Medical and insurance companies are forever changing hands, meaning you could know exactly who you are billing one day only to find them subsumed into a larger entity the next day. Obviously, no one lives in Doc Baker’s fantasy world, but taking a proactive approach to billing for orthotics can certainly help reduce time-consuming conflicts with insurers and possibly enhance reimbursement for your services. Mr. Smith is a freelance writer who lives in Cleona, Pa.