Home Health & Hospice Week

Tip:  You may not have to use an 'L' code for orthotic fabrication.

If you're not taking advantage of new CPT codes for orthotic fabrication, you could be missing out on your rightful reimbursement.

A brand new, three-code category titled "Orthotic Management and Prosthetic Management" took effect Jan. 1. The codes replace deleted 97504, 97520 and 97703--and they'll provide more options for reimbursing orthotic fabrication.

The only significant difference between deleted 97504 (Orthotic(s) fitting and training, upper extremity(s), lower extremity(s), and/or trunk, each 15 minutes) and the new 97760 (Orthotic(s) management and training [including assessment and fitting when not otherwise reported], upper extremity(s) and/or trunk, each 15 minutes) is the addition of the word "management."  But this simple change carries a lot of weight.

Good news: The American Medical Association added "management" to better define what therapy services the code described, points out physical therapist Rick Gawenda, director of physical medicine & rehabilitation at Detroit Receiving Hospital in Detroit. "Before, there was a lot of confusion over whether 97504 included orthotic fabrication," Gawenda says. But now, the agency's rationale says management includes "designing, selecting and fabricating the orthotic."

This means your therapists may not have to use an L-code to cover orthotic fabrication. For example, a therapist fitting a patient with a wrist orthotic might use L3800 (WHFO, short opponens, no attachments, custom fabricated) to supplement 97504 in order to cover fabrication costs. But the new code 97760 implies the inclusion of these costs "when not otherwise reported."

"I see this as a good change because covering the softer costs of splinting is sometimes difficult, and the L-codes do not always accurately capture all the costs," says Irene Bartlett, PT rehab director at Mercy Medical Center in Des Moines, IA. "This change may also help places that are unable to use L-codes."

Avoid Double-Dipping

Experts warn: The AMA has not eliminated the option of using L-codes, so your therapists need to tread carefully if they continue to use them with 97760--or their claims could be denied for reporting the same thing twice.

"In 97760's description, the phrase 'when not otherwise reported' tells me that if I still bill the L-code for fabricating, then I shouldn't count that time in with 97760 because I'm reporting it somewhere else," Gawenda offers. "But if I don't bill the L-code, then I can put those minutes under 97760--so it seems to be giving the provider a choice."

Watch for: Your therapists' coding concerns aren't over once they've conquered the L-codes because they'll still want to watch for the National Correct Coding Initiative (NCCI) edits. Even though 97760 is a new code, it will most likely still carry the same denial that 97504 has when paired with 97116 (Therapeutic procedure, one or more areas, each 15 minutes; gait training [includes stair climbing]).

So, take care when billing 97760 and 97116 on separate extremities on the same day, advises Robin Roach, president of Health Data Solutions Inc. in Charleston, WV. Your therapists would need to apply modifier 59 to 97116 and thoroughly document the codes as two distinct procedures and extremities, she says. Modifier 59 makes sure the claims office knows that 97760 and 97716 are distinct procedural services since these codes are "bundled."

More new codes: To keep all orthotic and prosthetic management codes under one heading, CPT introduced codes 97761 (Prosthetic training, upper and/or lower extremity(s), each 15 minutes) and 97762 (Checkout for orthotic/prosthetic use, established patient, each 15 minutes).

They merely replace 97520 (Prosthetic training, upper and/or lower extremities, each 15 minutes) and 97703 (Checkout for orthotic/prosthetic use, established patient, each 15 minutes), but do not change the way your therapists report the codes, and the definitions stay the same, Gawenda reminds.