Clinical Best Practices for Orthotics

Start By Scanning Every New Patient

We know that when the foot hits the ground, everything changes. Providers must consider the feet, which are the foundation of the patient’s spine when evaluating the musculoskeletal system relative to the patient’s complaints. Best practice is to scan every patient at the beginning of their episode of care.

The valuable data collected with the 3D, digital scan is the most important starting point. Not only does the scan measure the arches of the feet, but also indicates degrees of pronation or supination and many other measurements that demonstrate medical necessity for functional orthotics. Whether the provider elects to order the functional orthotics right away or include them in later recommendations, this important scan provides information to support the prescription of chiropractic care as well. We recommend that your foot scan becomes an integral part of the evaluation, just as vital signs are “automatic.” The following steps are recommended to identify additional, important details to support the provider’s recommendations.

Evaluate Medical Necessity and Document Your Clinical Decision Making

Documentation of medical necessity of care starts with the patient’s history. When considering whether functional orthotics are medically necessary, and therefore a covered service, insurers often look to the patient history to document the following symptoms where present:

    • joint pain/stiffness
    • weakness
    • limitation of motion
    • difficulty walking
    • numbness/tingling in the lower extremities

It is important when taking a patient’s history to explore both past and current medical conditions that may affect patient care. Chronic conditions and traumatic injuries could each benefit from functional orthotics. Additionally, it may be helpful to ask the patient about other treatments tried or considered and ruled out. Where applicable, document why these prior alternatives did not work out favorably, or why they stopped working.

These are some examples of specific history questions that may be helpful in determining the need for functional orthotics:

    • Are your symptoms affected by walking, standing, or climbing stairs?
    • Do you avoid activity due to pain in your feet or lower extremities?
    • Do you have to elevate your feet to get comfortable?
    • Do you use any type of home remedies for your feet and lower extremities?
    • Have you tried heel lifts, over the counter (OTC) analgesics, OTC insoles, rigid orthotics, padding, changing your shoes, or injections?

The answers to these questions, when properly documented in the patient record, may help support your assessment that treatment is indicated and there is medical necessity for prescribing functional orthotics.

Examination And Diagnostic Testing

Once the patient’s history is established, the next step is the physical examination, with the testing driven by what was learned in the history. The history, combined with documentation of the physical examination and, where called for, diagnostic testing (i.e., X-rays) together provides the objective evidence for medical necessity to support the use of functional orthotics in a treatment program. When orthotics are being considered, your documentation must clearly describe the patients’ symptoms and medical diagnoses. You may also include one or more of the following:

    • 5 Red Flags of Pronation
    • Global postural distortions
    • Structural X-ray anomalies
    • Functional squat test
    • Range of motion
    • Orthopedic/Neurological tests
    • Digital foot/posture assessment

Click here to access an excellent Functional Foot Evaluation form to best document clinical findings.

Proper Diagnosis

Functional orthotics address not only conditions of the feet, legs, and hips but also conditions of the spine. Most often, insurance coverage is limited to diagnoses specific to extremities vs. spinal conditions. For this reason, we urge providers to be aware of the diagnosis requirements for medical necessity when attempting to assist the patient with receiving reimbursement from a third-party payer. The Medical Review Policy (MRP), published by the payer, should outline all the requirements. If the patient’s condition is not included in the medically necessary diagnosis list, not to worry. The patient still needs functional orthotics! Simply prescribe them as you would otherwise. In this course, we provide a list of diagnosis codes that have appeared in various payer MRP. However, this list is not exhaustive and shouldn’t be relied upon as the definitive list of appropriate diagnosis codes.

Treatment Plan

To establish medical necessity and the clinical appropriateness of functional orthotics, include your recommendations in the context of a broader treatment plan. A properly written treatment plan should be comprehensive and may include some of the following elements:

    • Recommended level of care to include duration and frequency of follow-up visits
    • Methods of treatment to be utilized (i.e., adjustments, therapies, functional orthotics, rehab)
    • Specific treatment goals, including goals for the functional orthotics
    • Objective measures to evaluate treatment effectiveness and the effectiveness of functional orthotics
    • Planned modalities and procedures, including those adjunctive treatments to support the necessity of functional orthotics

Finally, ensure that your initial or ongoing assessment indicates the provider’s reasoning for prescribing functional orthotics. This is where providers lay out the analysis of the data obtained throughout this evaluation process, culminating in the recommendation for functional orthotics.

**This is an excellent article and page of information about best practices: https://www.chiroeco.com/custom-orthotics-for-flat-feet/

Orthotics and Their Clinical Applications

Everything begins with the patient history and evaluation. When including the potential for custom orthotics in your patient’s treatment plan, begin with careful and comprehensive documentation of the patient’s condition. It includes asking the right questions and documenting important findings. This overview tutorial outlines the most important clinical aspects of the health record that may support the need for custom, functional orthotics.

FAQ-Orthotics Coverage

Orthotics Coverage FAQs

Q:

 I billed a carrier for orthotics, and when I got the check, it didn’t cover the price I paid for the orthotics—I’m essentially paying patients to wear them! I’m in-network with the carrier; do I have any options?
A: If you know the covered fee schedule is lower than the amount you paid for the orthotics, or the allowed amount is unreasonable regarding meeting your overall costs, you do have options. Depending on your contract with the carrier, try using the S1001 code billing concept outlined in the Foot Levelers Billing Guide.

Q:

 How much do I charge for the scan on the Foot Levelers 3D BodyView Scanner or Kiosk?
A: There is usually no additional fee for the evaluation when you are simply scanning the feet—the cost of the scan is included in the costs for the orthotics when they are ordered. If you are performing a separately identifiable Evaluation and Management (E/M) service with documentation that follows EM Guidelines, you can bill for the E/M service if appropriate. KMC University has a library full of E/M coding training and information available if you’re interested in maximizing your profits by documenting these services.

Q:

 How can I charge for my time spent fitting orthotics when they come from the manufacturer?
A: There is no exact rule for this; however, it may be appropriate to bill 97760 for the visit when you dispense the orthotics. The rules and coding guidelines set by the carrier you’re billing apply. Here is a description of the 97760 code:

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.

This code can be billed the day the functional orthotics are dispensed to the patient but can only be used for “custom fabricated” supports. The code includes the fitting for the functional orthotics; training in the use, care, and wear time of the functional orthotics, and brief instructions for exercises to practice while the functional orthotics are in place. Direct one-on-one contact by the provider is required, and it is a timed code so include the time in your documentation. All the services you provided that day should be outlined in your daily note.

Orthotics Reimbursement Options

The Reimbursement Path

Clinics must complete the verification process, consult the payer’s Medical Review Policy, and confirm the clinical need for orthotics. Then, it is time to decide which reimbursement path the clinic will pursue – self-pay or third-party pay. Keep in mind all required components of the No Surprises Act and any other federal guidelines when establishing both processes. Listed below is a brief list of considerations for each reimbursement path.

Insurance Reimbursement Patient Self-Pay
The patient’s medical record demonstrates the payer’s documentation requirements for prescribing functional orthotics. The patient’s medical record documentation meets minimum state regulations and/or board documentation requirements.
Documentation includes essential information to support the allowed conditions for which functional orthotics may be prescribed, per the payer’s Medical Review Policy (MRP). The practice must offer a Good Faith Estimate (GFE) to include functional orthotics costs if the patient is not utilizing insurance for any service rendered in the clinic or is uninsured.
ICD-10 diagnosis codes must match the allowed conditions to the highest level of specificity and point to the functional orthotics CPT (Current Procedural Terminology) ® codes. When the payers’ definitions of coverage do not include the patient’s condition/diagnosis, the practice must obtain an Advance Notice to Member for Non-covered Services on the payers’ form or their own.
Verify that the allowed fee for the functional orthotics exceeds the doctor’s cost. If not, initiate the option to use S1001 code for luxury items, if allowed, with notice to the patient. When the practice fee schedule for functional orthotics is too steep for self-pay patients, consider membership in ChiroHealthUSA, a Discount Medical Plan Organization (DMPO) network for legal discounts.
Code ancillary services, like orthotics management and training, when appropriate, to describe additional work by the provider that is associated with the prescription of the functional orthotics, and expect payment from the third-party payer. Consider allowing the patient to pay for the functional orthotics and associated services over time. Implement a payment plan that works for the practice and the patient’s budget.

The Decision Point- Insurance or Cash?

Gather the Facts

Some patients’ insurance may cover functional orthotics, but more often, there are caveats to consider. Many payers are moving to a model in which all Durable Medical Equipment (DME) must be dispensed through an in-network DME Supplier in order to be covered. Some require that the prescription for the DME is only valid when ordered by an allopathic physician rather than a Chiropractor or other type of provider. Therefore, it’s critical to verify all insurance coverage thoroughly, asking all the right questions, to determine whether the patient’s benefits include functional orthotics. Be sure to check with each individual carrier as well as your state scope of practice that may require a spinal-related diagnosis, an extremity-related diagnosis, or both.

A Thorough Verification of Benefits

As with all aspects of Chiropractic care, a simple verification of coverage is never enough when dealing with orthotic coverage. Simply asking or reviewing whether a patient’s benefits include orthotics can leave a gaping hole in the information required to receive payment. For that reason, a multi-step process is recommended to protect the practice and the patient before ordering functional orthotics.

Follow these steps for success.

    • When– Verification of benefits can happen before your patient comes in. You can copy the orthotics verification template page and place it on the back side of your existing verification form. Collect necessary information on the intake phone call and pre-verify benefits. For practices that scan every new patient, as recommended, verify orthotic benefits right along with other chiropractic benefits. Then, if functional orthotics are ordered, you have all the information necessary to bill and collect properly.
    • What– To get all the answers you need, specific questions must be asked in a very specific way. For that reason, we’ve supplied a template verification form for your use. The questions on this form are carefully curated to guide you through the potential land mines associated with orthotics billing. We urge you to follow the form exactly, adding additional questions as they may relate specifically to your office.
    • Where– Reviewing an online benefits portal is probably not enough to get you all the information you’ll need to bill orthotics. Basic coverage information is rarely sufficient to help you know all the nuances that may be in play. We urge you to always check for the Medical Review Policy (MRP) for Orthotics and Prosthetics on the Payer’s website. It will delve into the specifics of which diagnoses are covered and under what circumstances orthotics are considered medically necessary.
    • Why– Once you have reviewed that MRP, investigate the patient’s specific benefits. The form will direct you to questions such as the allowed fee per foot, which codes are covered, co-insurance percentage, and additional ancillary services that may be covered. This deeper dive is important to arm you with all the information needed for successful billing.

Now What?

So, what happens if your investigation reveals that the patient doesn’t have full insurance coverage for functional orthotics or the patient’s diagnosis is not consistent with coverage? This happens quite often, but it doesn’t mean the patient’s needs change. Now is the time for the provider to prescribe, regardless of coverage, and as with all care, have your teamwork with patients to make the orthotics affordable within their family budget. The next page explains some options for self-pay patients.

Template Letter-Amend Provider Agreement to Use S1001

Download Support Tool

This template is an example of a letter you may send to your provider relations department to request an amendment to your agreement. This amendment allows you to offer items to your patient that may be enhanced or luxury items that could cost more than the traditional fee allowed for the item, per your agreement. NOTE: Once you click on the resource, look for the document in your downloads or taskbar. Unlike a PDF, these will not open up on your desktop.

Template Letter-Amend Provider Agreement to Use S1001