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September, 2010

Billing for Custom-Made Orthotics

By K. Jeffrey Miller, DC, DABCO

Adding custom-made orthotics to your practice can not only be another revenue stream for you, but it will also give more benefit to your current patients and may even bring in some new ones. Of course, to properly incorporate custom-made orthotics into your practice, you must know how to properly bill and code so that you will be appropriately reimbursed. The key to billing for custom-made orthotics lies in correct verification of the patient's insurance coverage for durable medical equipment (DME). Once the verification is completed, the office staff and doctor will know if coverage exists or if the orthotics will be dealt with on a cash basis. The verification for orthotics as well as other DMEs is specific and should be separate from the standard verification process for chiropractic care in general. This is because most general verification processes and the forms used typically ask only a couple of questions about DMEs and do not go into specific details. The devil is in those details.

Questions You Should Ask the Carrier

Are custom-molded foot inserts (orthotics) covered and billed as code L3020? The emphasis here is on the "custom-molded" and "L3020" code. The products in question are not just off the shelf. This point must be stressed with the carrier. The L3020 code is the most frequent and accurate code used to bill for custom-made orthotics.

If the L3020 code is not accepted, can the code L3030 be used? This is the next most frequent/accurate code for custom-made, flexible orthotics. In fact, some states only accept this code. This will not be known if the verification process is not performed.

Are there guidelines or limits on the use of the codes? You will need to ask the carrier this question about the code they cover: Are there condition-related limitations or reimbursement-related limitations?

Are the orthotics or other DMEs part of a separate policy benefit? In some cases, custom-made orthotics are listed in a separate benefit category. They are considered separate since they will be reviewed independently of other methods of chiropractic care. They may also have to be filed separately with accompanying documentation showing medical necessity. It is good to ask about orthotics and other DMEs as you may discover specific information for the billing of those other DMEs (i.e., pillows).

Are documents related to medical necessity required with submission of the claim? You need to know this information ahead of time to reduce the chances of having to re-file the claim.

Do required documents for medical necessity include a prescription from a physician/chiropractor? If this is yes, include it with the claim and other documentation.

Are custom-made orthotics subject to a separate co-pay or co-insurance? This is not uncommon. You will have to take the time to explain this to the patient who is used to a single, fixed co-pay.

Are there specific diagnosis codes that cover or do not cover orthotics? Once the carrier has answered this question, remember the patient's condition is only what the examination results can confirm and back up. If the diagnosis does not match the covered diagnoses or only matches the noncovered diagnoses, the orthotics will be a cash product. Once you know this, it must be determined if the product is out of network and if fees can be collected from the patient.

Cash Payments

If the answers to the initial questions regarding the codes L3020 and L3030 are "no," then the custom-made orthotics are going to be a cash transaction. Do not use any other codes. The two codes listed are the only accurate ones. This does not mean the verification is over. There are still several codes that apply to the recommendation, fitting and use of custom-made orthotics. They may provide coverage for care related to the application of orthotics.

New and established patient-examination codes apply to the evaluation required to determine if orthotics are necessary. The evaluation techniques employed by the doctor are simply included in the level of code that is indicated by these procedures in combination with other diagnostic techniques. X-rays of the feet, knees, hips and pelvis may be necessary and are covered services. Orthotic management, training and checkout codes 97760 and 97762 apply for dispensing and also for later checking on orthotic use. Taping of the foot and ankle may be required to demonstrate the need for orthotics to the patient and/or to support the patient while the orthotics are being custom made. This is the 29540 code. Last, but not least, is the code 98943 for extremity adjusting. This is almost a given, but should still be stressed.

Many carriers do not provide coverage for custom-made orthotics, making the supports a cash product. However, even with this in mind, the doctor owes it to the patient to verify coverage or the lack thereof. This allows the patient to take advantage of coverage when it's available. The doctor also owes it to their practice to see that verification allows accurate billing and reimbursement, whether it is for covered or non-covered orthotics.


Verification Checklist

Here are some questions you will want to have on hand when verifying an insurance carrier's coverage for orthotics:

  • Are custom-molded foot inserts, with longitudinal/metatarsal support, covered typically billed as code L3020?

If yes:

  • Is there a maximal limit of payout per diagnosis? Per year?
  • What is the percentage of coverage allowed?
  • Are there certain diagnosis codes necessary for reimbursement under the policy?
  • If yes, what are they or where can I find them?
  • Is a Letter of Medical Necessity needed?
  • Is a prescription from a physician required?
  • If yes, can the RX be from a doctor of chiropractic?
  • Are these products subject to the deductible?
  • Do you cover code 98943 when performed by a DC?
  • Do you cover Orthotics Management and Training, code 97760?
  • Do you cover Orthotics Check Out, code 97762?
  • Are rehabilitative codes, such as 97110 covered under the policy?
  • Do you cover strapping/taping, when billed as code 29540?

If no (Remember, although the product itself may be specifically not covered, the ancillary services provided are probably covered under the policy):

  • Where in my patient's policy book can they find the specific note that these supplies are non-covered?
  • Do you cover code 98943 when performed by a DC?
  • Do you cover Orthotics Management and Training, code 97760?
  • Are rehabilitative codes, such as 97110 covered under the policy?
  • Do you cover Orthotics Check Out, code 97762?
  • Do you cover strapping/taping, when billed as code 29540?

*Information available at www.kathymillschang.com/pdf/HTGPO.pdf


Click here for more information about K. Jeffrey Miller, DC, DABCO.

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