The last 6 installments of this column have provided some insights into proper documentation and coding of the foot orthotic device itself.
This installment will discuss the proper completion of the claim form for custom foot orthotics.
The first step in completion of the bottom portion of the claim form is choosing the correct ICD10 diagnosis code. This may seem simple especially if the patient has a condition which is bilateral or for which the ICD10 code does not require laterality. An example is plantar fasciitis (M72.2) for which there is no additional extension to indicate left and/or right. However, a similar condition calcaneal spur may be supported by ICD10 M77.31 (right foot) and M77.32 left foot. What is critical here is that the third party payer may either ask for follow up information to support payment for both feet when an ICD10 code which uses laterality is provided. If a patient has a diagnosis which requires laterality, one must be able to support the use of the device (as with eye glasses) on the contralateral limb. There is no easy answer to this scenario as many carriers are insistent on only paying for the pathological side. Thus going back to the original article in this series, one needs to inquire on whether or not the “normal” side will also be covered.
Which HCPCS code to use?
The HCPCS code for the devices should be chosen based on the properties of the devices. Many private carriers have fee schedules which are the same no matter the code (L3000-L3020) while others pay more for one code or another. This despite your costs for providing any of these devices may be the same. It is nevertheless important to choose the HCPCS code which most represents the HCPCS code.
Can I bill the HCPCS codes as 2 units or should they be billed on separate lines?
The HCPCS code should never be billed on one line with 2 units. Correct coding requires that each side (LT or RT) is to be billed on a separate line.
Referring Physician?
Because foot orthotics are considered DME, even when billing non-Medicare carriers, the referring (prescribing) physicians’ name should appear in box 17 along with their NPI in box 17B. Though that may be you, most insurance carriers (yes even non-Medicare carriers) will require this information in order for the claim to be considered clean.
What about billing for casting the patient?
The code which best describes this is S0395. Note that this code does not include the use of bio foam or scanning. S0395 is primarily to be used in scenarios where the provider of the device is not the manufacturer. This does reflect the scenario for most podiatrists and some orthotists and pedorthists who use central fabricating labs like Kevin Root. Other codes which are entirely inaccurate to describe the casting of patients for orthotics frequently denied on audit are “A” supply codes or” Q” codes for fractures/sprains as is the use of the supply code 99070.
However, most third-party payers include the casting of the patient as part of the reimbursement for the devices and thus there is no additional reimbursement for S0395. Those providers who self-manufacture their own devices are not advised to use this code.
What is the correct date of service (DOS) to bill foot orthotics?
This is one of the most frequently asked questions and one which third party payers often view as abused.
When a patient is billed for any custom fabricated item on the same date as the initial office visit, this will almost certainly be recouped on a post payment audit. Most carriers have now installed coding edits to preclude payment of any custom fabricated item when the patient is billed for an initial evaluation and management service on the same date.
In most cases, the correct date of service must correspond to the date on the written proof of delivery. Billing for custom fabricated foot orthotics prior to delivery will almost always be argued by the carrier as inconsistent to their policies. While providers argue that they incur expenses on the date they image the patients, the carriers will almost always counter that the HCPCS code includes the actual delivery of the device and their policy may refer to the general Medicare guidelines for DMEPOS. Researching your third-party payers DMEPOS reimbursement policy can sometimes provide you with guidance on choosing the correct DOS.
Regarding patients who do not pick up their orthotics, most payers will have clauses which cover recovering the costs for orthotics which were not dispensed.
The next installment on this article will cover how to handle Medicare patients whose secondary insurance will cover custom foot orthotics while Medicare does not.
