Millions of Medicare beneficiaries in the US rely on durable medical equipment (DME) which includes canes, nebulizers, blood sugar monitors, and other medically necessary supplies. These DMEs are expensive hence physicians should aware of billing for Orthotics and DME as lower reimbursements negatively impacted your revenue cycle management.
DMEs are necessary to improve quality of life and maintain the independence of patients at home however, due to dynamic regulatory compliances billing of orthotics and DME are renovating. It is observed that DME accounts for only 2% of total healthcare costs in the United States, however, these supplies are important in preventing injuries and supporting the health of millions on Medicare.
DME Coverage for Medicare
During a short-term stay at a skilled nursing facility or hospital, Medicare does not cover DME. However, it only pays for the basic level of DME products available for any given condition.
Some of the covered products include:
- Diabetic supplies
- Wheelchairs and Mobility Scooters
- Canes, Crutches, and Walkers
- Continuous Positive Airway Pressure (CPAP) devices
- Commode Chairs
- Nebulizers and Nebulizer Medications
- Oxygen and Related Supplies
- Hospital Beds
Now let’s look at how physicians can bill for Orthotics and DME by using general billing requirements and different codes used by providers to bill Orthotics and DME.
Steps for Orthotics and DME billing
- DME requires a prescription to rent or purchase, as applicable, before it is eligible for coverage.
- Bill on a typed CMS-1500 (version 08/05) claim form.
- After all HCPCS codes, bill the applicable modifier (including, but not limited to NU, RR, etc).
- After the procedure code bill maintenance and repair modifier codes.
- All claims for repairs submitted with a complete description of the services provided.
- If no suitable HCPCS billing code exists then only use E1399 or other miscellaneous HCPCS codes
There must be the inclusion of special documentation for each claim with miscellaneous codes or custom items (i.e., foot orthotics, specialty wheelchairs):
- Always submit a complete description of the item.
- With the initial claim, submit a factory invoice for the item (catalogs and retail price listings are not acceptable) and, if appropriate, a certificate of medical necessity form with the physician’s signature.
- Do not staple this documentation to the claim form.
- Submit all initial claims on paper to ensure that the appropriate documentation is received in the same envelope.
- The additional documentation cannot be transmitted with electronically submitted claims.
When it comes to bill for orthotics Common Procedural Terminology codes for orthotic management and training and prosthetic management are appropriate to use to fabricate a custom brace, or to train a client on the proper use of a custom fabricated or prefabricated orthotic. However, sometimes it may be necessary to bill an L code for an orthotic.
Let’s understand different codes providers can use to bill for orthotics. Below are some tips which show the right code for the provided service.
CPT codes for Orthotics billing
CPT Code 97760 : Orthotics Initial Encounter Code
Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes. (Ref)
CPT Code 97761
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes.
CPT Code 97763
Orthotic(s)/prosthetic(s) management and/or training, upper extremity (ies), lower extremity (ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes.
The evaluation and fitting components of the service included in HCPCS L-codes for orthotics. But training time associated with using the orthotic is reported using CPT code 97760. Let’s understand the Orthotics L code and when it is appropriate to bill Medicare.
Orthotics L Code-
If the orthotic is not fabricated on-site, it will most likely have an appropriate L code for billing. Some practitioners will prefer to send patients to suppliers while others keep a supply of these orthotics in the therapy clinic. In the former stage, the supplier will bill Medicare directly for the orthotic, and in a later stage, practitioners will bill Medicare when they are dispensed.
Additional orthotic management and training during follow-up visits are covered with CPT code 97760, including:
- Exercises performed in the orthotic.
- Instruction about skincare and orthotic wearing time.
- The time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity.
For orthotics, Medicare reimbursement includes:
- measurement and/or fitting,
- fabrication and customization,
- cost of labor, and
Finally, we can talk about coverage for DME add ons where “Standard DME” is referred to as an entity that will adequately meet the medical needs of the patient and is not customized for a specific individual’s use. While “Nonstandard DME” is any item that has certain convenience or luxury features.
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