Orthopedic Coding Alert

Question: During an office visit with an established patient, the provider performs an orthotic fitting on the patient’s left arm; notes indicate that the provider was “finding best-fitting orthotic” for the patient. Is this an evaluation and management (E/M) service, an orthotic management service, or both?

Illinois Subscriber

Answer: If depends on the purpose of the fitting. The encounter notes indicate that the provider was fitting the orthotic; if that is the sole purpose of the fitting, you’ll report the service with the appropriate E/M code from the 99211(Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal …) to 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) code set.

If, however, the provider went further than fitting the orthotic, you might choose a different coding option. Let’s say that the provider fitted the orthotic, then spent time discussing skin care for the orthotic area and what to do if the orthotic causes the patients any problems or discomfort. Total encounter time was 38 minutes. In this case, the orthotic service went beyond fitting and into training/management. When this type of service occurs, your best bet is 97760 (Orthotic[s] management and training [including assessment and fitting when not otherwise reported], upper extremity[s], lower extremity[s] and/or trunk, each 15 minutes). Since this is a time-based code, you would report 97760 x 2 for this encounter, if you choose to go that coding route.

As always with one-sided procedures, you might also need to append modifier LT (Left side) to 97760 if you choose this code for the claim and the payer requires laterality modifiers.