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How To Master Billing For Orthotics

Orthotics are an integral part of podiatric practice. They provide viable treatment options for many conditions that we treat. However, there are also associated hard costs with orthotics that can be a financial detriment to the practice if the office cannot collect fees in a timely fashion. Obviously, your staff should be very aware of coverage criteria for the principal insurance companies that your office commonly deals with when it comes to payment for any service rendered in the office. This will save a lot of time in determining whether orthotics may be a covered benefit for the patient. In regard to lesser known insurance companies, it is wise for office staff to contact them in order to determine eligibility and coverage criteria. Collecting payment for dispensed orthotics seems to be a sticking point for many offices. Custom orthotics are not inexpensive so affordability becomes an issue. Being upfront with the patient in regard to your fees will put all parties on the same page. This candor allows patients the opportunity to decide if they wish to proceed with obtaining orthotics if the insurance company does not pay for them. Each office should devise a form that states the cost of the orthotics and associated charges such as casting, orthotic adjustments, etc. Your office should also devise a policy as to what is included in the orthotic fee especially when it comes to patients who are paying cash. If the insurance carrier does not cover orthotics, many of the services we commonly perform in conjunction with orthotics may not be covered as well. For example, Medicare does not pay for foot orthotics (unless they are associated in a diabetic shoe or with the shoe that is attached to a brace). Medicare will also not pay for range of motion and muscle testing if the testing is related to orthotic fabrication, casting, dispensing and adjustments to the orthotics. Addressing Informed Consent And Patient Expectations With any type of service we provide, we need to obtain informed consent.We do not proceed with a surgery without explaining certain risks and benefits. If you cannot meet the patient’s expectations for the surgery, then obviously the patient will be disappointed. Give similar consideration to orthotic devices.Although orthotics can make patients better, they cannot always offer the ideal therapeutic solution. Patients will continue to have high arch or low arch feet, and may accordingly be subject to strain and stress with increased activities. Patients need to be aware that the intent of the orthotics is to improve the function of the foot but the DPM can give no guarantees that the patient will be pain-free. I use the analogy of a pair of eyeglasses in the office. Orthotics do not alter the foot but they simply make it work better.There are no guarantees that glasses will give the patient 20/20 vision or that orthotics can allow the patient pain-free activity levels. Unlike a pair of glasses, which you can pretty much tell immediately if they work, orthotics will not offer instantaneous improvements but will offer benefits over the course of weeks and months. Also discuss shoe gear with patients to better determine the proper type of orthotic to prescribe. Patients may be upset if they find that the orthotics fit a very limited number of shoes. The more patients are aware of how orthotics work, the more compliance and satisfaction you will see in these patients. Have patients sign a payment agreement. This is helpful in documenting that they understand their responsibilities and realize the service may not be covered by their insurance carrier. Also be upfront with the patient when insurance coverage by the carrier is unclear. Most carriers, even if they render an authorization, will still have a disclaimer.The patient’s policy must be active at the time of service and the services must be medically necessary. Keys To Effective Chart Notes The chart should clearly document the patient’s diagnosis, the severity and duration of the condition, and the conservative options you attempted. The conservative modalities may include shoe modifications/ padding, the use of over-thecounter (OTC) devices, strapping, etc. Simply stating the patient has plantar fasciitis is not sufficient to warrant an orthotic. Any letter for medical necessity should basically state why this patient with this particular diagnosis needs this particular device at this particular time. Do not make blanket statements about orthotics (what materials they are made of, general biomechanical theory behind orthotic therapy, etc) that do not attest to the medical necessity for that patient. One should bill orthotics utilizing two lines on the claim form, one for the right foot and one for the left foot.This seems to be less confusing to the insurance carriers than billing one line with units 2 in box 24 G of the CMS 1500 form. A Few Thoughts About Insurance Company Fees And Orthotics With regard to fees for orthotics, if you have a contract with an insurance carrier that covers orthotic devices, then you are bound to that fee schedule. If you find that the fee is too low, make sure that the fee is for a single orthotic, not for a pair. You should renegotiate your contract regarding orthotics to make sure it is worth your while to dispense them. In a capitated fee environment, orthotics can be carved out of your capitated payment since there is a hard cost associated with the device beyond any professional component. If you find that the contract allowance is unfairly low, you may find it more cost effective to simply refer these patients to a designated orthotic facility. Please check the language of your contract to make sure you are allowed to refer the patient. Dispensing Orthotics: Determining What Is And Is Not Covered When determining orthotic therapy, one decision is whether to recommend OTC versus custom-made devices. Patients have often already tried such devices before they come to your practice and you should document this in the chart. Over-the-counter orthotics that one dispenses in the office are generally not covered by insurance carriers and these devices usually involve direct cash payment from the patient. Many patients have health savings accounts (or “cafeteria plans”). In these situations, your staff generates a bill for the patient so he or she can get reimbursed from one of these accounts. Patients will still be paying you cash at the time of delivery of the items. The dispensing of orthotics is generally included in the cost of the orthotic.There are codes for orthotic dispensing but these are for orthotists and not for physicians who provide professional services. Check with each insurance carrier regarding its guidelines for orthotic follow-up. Consider the office visit of a patient who complains that an edge of the orthotic is causing pain. In this case, the patient needs a simple orthotic adjustment. Consider the office visit of another patient who you are evaluating for plantar fasciitis to see if the orthotic is making a positive impact or if you need to alter your treatment course. There is no E/M component in the orthotic adjustment scenario whereas there is an E/M component when it comes to following up on the patient’s treatment progress. One error that office staff and clinicians commonly make is billing L3030 orthotic devices with an associated casting fee.The description of a L3030 device is a device that one molds directly to the patient’s foot. Obtaining a plaster mold/cast would not be appropriate for this code series. The next determination is the use of L3000 versus L3020. In regard to an orthotic that has a posted heel with a deep heel cup, it is best to bill this as an L3000 device. The L3020 does not have a heel post and is described as a longitudinal arch support in the American Orthotic and Prosthetic Association manual. It is important for you and your staff to familiarize yourselves with these descriptions of the various orthotic types in order to bill the appropriate device and ensure that your chart note backs up this code selection. Also be aware that each carrier may have its own policies as to what orthotic codes it may allow. Again, make sure your staff is aware of these policies. A Guide To Coding For Specific Services Casting. There is no specific CPT code for casting for orthotic devices. It is recommended to use the unlisted casting code 29799 for this purpose. Bill this code once. However, your claim form should clarify what you are including within this code. It includes both the professional component of obtaining a mold as well as cast supplies. It is inappropriate to use A4590 or A4580 as this would imply that you used an entire roll of plaster/synthetic material to obtain this mold. Generally only a few strips of plaster are required so these codes would not be appropriate. There is also no code for scanning orthotic devices. There is no professional component to scanning for an orthotic device as a machine does this. Most insurance companies are not currently paying for this technology. Gait analysis. Another code that practices commonly bill with orthotics is coding for gait analysis. The CPT code 96000-96004 is for computerized gait analysis. There are many machines on the market that offer “computerized gait analysis.” This code specifically states that this test needs to be done in a dedicated facility that utilizes full 3-D capabilities with cameras mounted at multiple angles to assess gait. One would use this code when evaluating patients with conditions such as cerebral palsy. In this instance, one would need to assess gait from all angles. On the other hand, one would not use this code when it comes to observing the gait of a patient who has been diagnosed with plantar fasciitis. It is best to bill gait analysis as part of the E/M service. Range of motion studies and muscle testing. You must document the medical necessity and reasonableness of each of these tests. Is there clinical evidence of any muscle weakness to warrant muscle testing? Is there a history of neurologic damage or other systemic diseases such as multiple sclerosis that might affect muscle weakness? If the patient simply has biomechanical abnormalities, then this test is of questionable value and medical necessity. Ranges of motion studies imply a complete extremity examination. This involves assessing hip, knee, ankle and foot function. Is it medically necessary to evaluate the entire leg when dealing with a limited foot condition? You must document the rationale to validate performing these tests. Medical Necessity: When Does It Come Into Play For Multiple Pairs And Orthotics In Diabetic Shoes? Multiple pairs. You should also develop office protocols for the fabrication of multiple pairs. Many carriers will only allow for a single pair of orthotics over a designated timeframe. However, there are patients who require different shoe gear as part of their normal job activities. There will be more of a medical necessity component and it is worth appealing to the carrier.This is in comparison to a patient who wants multiple orthotics to accommodate various styles of shoes/activities. Many labs will keep the orthotic mold on file for many years such so all it takes is a phone call to obtain second pairs. Consider an office policy with a discount for multiple pairs as there is very little office work required in comparison to the initial orthotic fabrication. Diabetic shoes/orthotics. These are only covered when there is documentation of diabetic neuropathy, ulcerations, etc. A patient with diabetes who simply needs an orthotic for a musculoskeletal component, such as plantar fasciitis (without the associated risk factors), would still not be covered.

Anthony Poggio, DPM



Great Article. We have been using the L3030 code across the board as our doctor says its what we need to do. We bill the initial E/M code along with the L3030. When the patient returns to pick up the orthotics, we don't charge. I know we are loosing money; what is a better description of L3030 -Why is a plaster/cast mold not L3030? What material is for L3030?
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