Eli's Rehab Report

Question: An occupational therapist in our outpatient clinic often creates and customizes splints and then instructs our patients on how to use them. We have been billing 97760 for this service,  but our claims are now being denied. Our payer says 97760 is too close to 97110 and will not reimburse for the code. Should we appeal the decision or change the way we bill?

Illinois Subscriber

Answer: Your first step should always be to go back to the therapist's documentation, which should clearly support your choice of 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), says Rick Gawenda, PT, president of Gawenda Seminars & Consulting. Any gray areas or vague comments could justify your payer's decision that 97110 better fits the scenario. If you're still convinced that 97760 is the correct code for your OT's work, you should "appeal the denials to obtain your reimbursement," Gawenda says.

97760 reimburses your clinic for the cost of providing orthotics and spending 15 minutes teaching patients to use them. You'd report 97710 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) for therapy you provide once a splint is administered.

Better: Rather than submit either 97760 or 97110, stick to the L codes, suggests Daniel Acker, therapy manager with Georgia Hand Shoulder and Elbow Surgery in Atlanta. "L codes are quite generous, so we accept that fee schedule unless we truly spend a significant amount of time training the patient how to use the device," he explains.

However, you should be wary of billing 97760 in conjunction with an L code. That's because 97760 covers assessment and fitting "when not otherwise reported," but your pay for the L codes also includes fitting and adjustment, points out Cheri Freeman, manager of account services for Virginia College Healthcare Reimbursement Services. Billing the codes together could look like asking for the same reimbursement twice.

Important: Make sure you bill your DMERC instead of your Medicare carrier for your therapist's work customizing splints. This approach will provide "more appropriate compensation for the time and materials you use to custom fabricate a splint," Freeman says.

The bottom line: You shouldn't resubmit your claim using a code you know will be paid unless you are certain it is the best description of the service performed, Gawenda stresses. You cannot simply swap out 97760 for 97110 unless 97110 is the best choice. Use your documentation of the actual service performed to determine whether to appeal or update your practices.