HCPCS Codes for Functional Orthotics

Coding for functional orthotics falls with the Healthcare Procedural Coding System, Level II codes, also known as “Hick Picks” codes. In 2012, representatives from three primary specialty associations* met to discuss the most common orthotic codes. The organizations mutually agreed on the more detailed guidelines for the device codes. Although the detailed guidelines are not formally part of the HCPCS code set descriptors, the guidelines have been adopted by some carriers as the descriptors that they will follow.

L3000

Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each:

This type of device is custom fabricated from a three-dimensional model of the patient’s foot (e.g., cast, foam impression, or virtual true 3-D digital image). This type of orthotic is a functional device, (reducing pathological forces) that has a molded heel cup and trim lines with a minimum of a 10 mm heel cup height to provide both medial and lateral directive forces to control the hind and forefoot. It may also have intrinsic or extrinsic posts designed to control foot motion. This device is made of a sufficiently rigid material to control function and reduce pathological forces. HCPCS code L3000 includes additions such as postings, padded top covers, soft tissue supplements, balance padding, and lesion or structure accommodations. Other additions may be required as well.

L3010

Foot, insert, removable, molded to patient model, longitudinal arch support, each:

This type of device is custom fabricated from a three-dimensional model of the patient’s foot (e.g., cast, foam impression, or virtual true 3-D digital image). This type of orthotic is an accommodative/functional device that has a heel cup of less than 10 mm and is intended to control the forefoot through a longitudinal arch support. It may also have intrinsic or extrinsic posts designed to control foot motion. This device is made of a sufficiently rigid material to reduce pathological forces. HCPCS code L3010 includes additions such as postings, padded top covers, soft tissue supplements, balance padding, and lesion or structure accommodations. Other additions may be required as well.

L3020

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each:

This type of device is custom fabricated from a three-dimensional model of the patient’s foot (e.g., cast, foam impression, or virtual true 3-D digital image). This type of orthotic is an accommodative/functional device that has a heel cup of less than 10 mm and is intended to control the forefoot through a Longitudinal Arch and metatarsal support. It may also have intrinsic or extrinsic posts designed to control foot motion. This device is made of a sufficiently rigid material to reduce pathological forces. HCPCS code L3020 includes additions such as postings, padded top covers, soft tissue supplements, balance padding, and lesion or structure accommodations. Other additions may be required as well. *This code most closely resembles Foot Levelers’ Functional Orthotics.

L3030

Foot insert, removable, formed to patient foot, each:

This type of device is custom formed directly to the patient’s foot through the use of an external heat source. The heat source should sufficiently and permanently alter the shape of the device, activating a resin, or other method by which the shape of the device is sufficiently and permanently altered to provide continuous contact with the unique characteristics of the plantar aspect of the patient’s foot. It may also have an intrinsic or extrinsic post designed to control foot motion. This type of orthotic is an accommodative functional device. This device is made of sufficiently rigid material to control foot motion and or reduce pathological forces. HCPCS code L3030 includes additions such as postings, padded top covers, soft tissue supplements, balance padding, and lesion or structure accommodations. Other additions may be required as well.

The preceding coding language has been approved by the American Podiatric Medical Association (APMA), American Orthotic and Prosthetic Association (AOPA), and Pedorthic Footcare Association (PFA) after a series of meetings, the most recent having occurred on May 13, 2016.

*L-Code Foot Orthotic Clarification Participating Organizations: American Orthotic and Prosthetic Association (AOPA) American Podiatric Medical Association (APMA) Pedorthic Footcare Association (PFA)

Billing and Coding Considerations for Orthotics

All codes are not the same – just because a code is covered by a health plan, it doesn’t mean it describes the functional orthotic being prescribed in your practice. Likewise, although we know that functional orthotics are proven to make a difference in lower back and other spinal pain that doesn’t mean the patient has a benefit for that diagnosis. This overview tutorial outlines best practices for proper HCPCS coding, modifiers, and ICD-10 coding necessary for payment.  

Tools for Financial Success

Download Support Tools

Download, review and save these important tools to assist with financial considerations in your practice. Self-pay patients are no longer the easiest patients in the clinic. Because of regulations such as the No Surprises Act, providers must acknowledge these patients at the time their appointment is made and offer them the choice to receive a Good Faith Estimate for the recommended services. This support tool will aid the clinic in identifying patient types that should be offered an estimate. Please keep in mind, the Good Faith Estimate is just a small part of this very complex rule. Be sure to check out KMC University’s more comprehensive training on the No Surprises Act along with all the tools you need to be compliant.

The customizable Acknowledgement to Self-Pay for Non-Covered Services support tool is intended for use when patients receive a service or procedure that is considered non-covered by their insurance and the patient is utilizing insurance for other services in the clinic. Locate the payer’s Advance Member Notice form, if any, before defaulting to the KMC University form. Payers often have their own forms. There may be specific services listed in the payer policy that cannot be included in an advance notice acknowledgment form (such as capitated services or bundled procedures). It is important to note that if patients are self-pay (not utilizing their insurance) and you are not filing a claim with their insurance, you need to follow the rules of the Good Faith Estimate as outlined by the No Surprises Act. These individuals receive notice of out-of-pocket expenses through that arrangement and specific form.

Patient Acknowledgement Form for Non-Covered Services
 No Surprises Act (NSA) GFE Decision Making Matrix

The Financial Report of Findings (FROF) Process

What is a FROF?

Most clinics are familiar with a report of findings. Depending on the setup in the clinic, the doctor may examine a patient, complete a report of findings, and treat the patient, all in one day. Others may complete the exam and take time for some additional ‘thinking’ before presenting their findings and treatment options. That provider may schedule the patient a few days after the initial exam. It can vary depending on the type of patient and the condition. No matter the process, a critical component of successful reimbursement is to complete a financial report of findings with the patient in addition to a clinical report of findings. The doctor can conduct it, if necessary, but we highly recommend a ‘passing of the baton’ to another staff member. This way the provider can concentrate on the clinical side while staff focus on the financial side.

The New Patient Data collection process is the first step in gathering the appropriate financial data. With the Good Faith Estimate regulations, a clinic is legally bound to have a financial conversation with the patient from the initial phone call. A clinic can use this as a stepping stone to establishing a financial agreement with the patient through a FROF process.

Consider the Schedule

Understanding your office flow and processes will help you prepare adequate time to develop your patient’s FROF. Every office is different. Some offices have patients come back the following day to receive the doctor’s Report of Findings as well as the FROF, while others schedule the patient for the following week. Will your patients receive their FROF the day following the initial examination or at some other time interval? Keep in mind, that the No Surprises Act forces a clinic to offer a Good Faith Estimate in most cases. You may want to take advantage of that conversation to build a hybrid FROF.

Consult the Treatment Plan

When evaluating this portion, be realistic. In some clinics, the doctor finishes all charts and treatment plans by the end of the business day while others may wait until the day of the patient’s second appointment to finalize the Report of Findings (ROF) information. If the provider is handing the baton, the doctor must collaborate closely with the team member to establish a process that works with both their schedules. Team members should speak up if they need the treatment plan sooner in order to present the financial information properly.

Verify Coverage and Benefits

Consumer empowerment has resulted in regulations that require payers to be more transparent with benefits and coverage. It includes insurance cards with more information on them, payer portals that list fees for all services as well as patient responsibility amounts in clear concise language. This may make the clinic’s job much easier, but until the infrastructure is in place, the old-school way of verifying benefits is a necessity. How does insurance verification take place in your office? Do you have this information verified and ready before patients ever arrive for their first visit as KMC University recommends, or do you have a process for obtaining this information after the initial visit? Determine how far in advance you will need this information to properly prepare your FROF and work with those responsible for this information to develop a useful and timely system. Pay special attention to items that are considered non-covered services by the payer, such as laser therapy or functional orthotics.

Initiate the Appropriate Form(s)

The financial process should be presented professionally. Have clean copies of all forms and present the information in a clear and concise manner. You may want to have pre-made folders with the necessary information based on the patient’s insurance status. Whether patients are utilizing their insurance benefits or are uninsured, the FROF will require you to locate the recommended treatment plan and work from there. Outlined below are different types of patients and the forms you might need.

    • Insured individual: Completed verification form outlining benefits and any out-of-pocket cost.
    • Insured but limited coverage: Completed verification form and copy of, or link to the clinical guidelines and payer limitations, along with their out-of-pocket cost.
    • Insured but limited reimbursement: In rare cases, if a patient were to choose a deluxe item, such as an upgraded, luxury version of functional orthotics, the payer may allow the beneficiary to pay the difference, up to the full retail price. This would require the provider to bill the HCPCS procedure code S1001. It would also require the provider to obtain a signed acknowledgment from the patient via an Advance Notice of Non-Coverage form. If the payer does not have an established form, default to the KMC University’s form. 
    • Insured but no coverage for orthotics: The verification form along with the patient’s policy or provider contract stating the service is not considered medically necessary. In order to pass the cost on to the patient, an Advance Notice of Non-Covered service form must be provided. If the payer does not have an established form, default to the KMC University’s form.
    • Insured but choosing to utilize a Discount Medical Plan Organization Network: ChiroHealthUSA allows you to customize your own levels of discounts for member patients even on products that insurance may not cover. Use their assigned forms in addition to the Verification form.
    • Insured but choosing not to utilize insurance: If the patient has requested that the clinic not bill a 3rd-party payer for any services they receive, they may be considered a self-pay individual as defined by the No Surprises Act. Offer a Good Faith Estimate and, if accepted, provide a customized form within the time period outlined by the regulation. If you are not familiar with this process, please consult the additional resources available on this topic in the KMC University member library.

Create a FROF Team and Provide Training

Once you have established a process, create a team to handle the FROF. Pick key people who are comfortable with financial discussions. Create scripting and train staff on how to manage financial discussions. Do not overlook the role each team member plays in the process, even those not assigned to conduct the FROF. Those who answer the phone and schedule have an important role in setting up the FROF process by gathering critical information and offering a Good Faith Estimate when necessary. Make sure the team member responsible for the FROF is not feeling rushed during the presentation. Confirm that all the forms are clear and easy to understand for the patient. Be sure to streamline this process for efficient delivery and practice scripting with staff.

Alternative Payment Options for Functional Orthotics

When the provider does not have the option of being reimbursed for orthotics by the patient’s Healthplan, they need to identify alternatives to reimbursement. Developing a solid understanding of other options can reduce financial anxiety for the patient and increase reimbursement for the clinic. Orthotics should not be prescribed based on the patient’s health insurance coverage. This tutorial will help you find ways to successfully incorporate an orthotic treatment plan for self-pay patients.

Orthotics & the Self-Pay Patient

Limited Benefits

Surveys show that fewer and fewer policies provide third-party coverage for functional orthotics. The lack of third-party financial assistance does not negate the fact that functional orthotics should be prescribed if indicated. Patients will pay out of pocket for their functional orthotics. It is reasonable to expect them to be willing to do so once they understand the importance of functional orthotics as well as their financial options and obligations.

Patients’ Rights

Healthcare laws have established many financial safeguards for both insured and uninsured patients. Most of the laws place patients in the driver’s seat when it comes to knowing their options when seeking healthcare. Patients can elect at any time not to utilize their insurance benefits. If they choose this option, the provider must offer a Good Faith Estimate as outlined by the No Surprises Act. An insured patient has the right to know about all out of pocket costs up front, and most payer portals are creating robust tools to provide this information to the patient. If a recommended service or treatment is considered non-covered, a contracted provider must consult the payer’s rules for billing non-covered services before passing on the cost to the patient. A patient who is insured or uninsured may opt to join a Discount Medical Plan Organization (DMPO) to manage out of pocket costs for items such as orthotics. When building the clinic’s financial policy, serious consideration must be given to different types of self-pay situations.

Charges and Fees Must be Compliant

It may be considered non-compliant when you have different fees for the same service for distinct types of patients. For example, your published fee schedule for L3020 is $250 per foot, but you wish to extend a time-of- service discounted fee of $150 per foot to uninsured or underinsured patients. This is outside the boundaries of a reasonable time-of-service discount according to the Office of Inspector General of the Department of Health and Human Services. Their guidance has indicated that a 5-15% discount is within normal margins unless you reside in one of the very few states that allow for a slightly larger discount. You have options, though.

Discounts May Lead to a Non-Compliant Dual Fee Schedule

In some states, offering patients time-of-service (TOS) or prompt-pay discounts is perfectly legal. The risk comes in determining how much of a discount you can provide as a prompt-pay incentive. You can’t give patients a TOS discount and then send them a bill. A simple way to avoid dual fee schedules is to join a cash discount network that allows plan members to enjoy discounted fees within your customized fee schedule. One of the most popular is ChiroHealthUSA, a network that allows the provider to set their discounted fees and member patients to access those discounted fees legally and compliantly. If you wish to offer discounted fees for functional orthotics to those without third-party assistance, this is one of the safest and most effective ways to do so. Many states now allow doctors to offer special concierge contracts for services/products, so it’s critical to know your state law.

Medicare is Not Likely to Cover Functional Orthotics

Functional orthotic inserts are covered by Medicare only when placed in a shoe attached to a brace. Medicare’s Durable Medical Equipment (DME) benefit also does not allow for these functional orthotics to be dispensed from a physician’s practice. Functional orthotics for Medicare patients will always be an excluded service under Medicare and you may charge the patient your full fee. Although the rules surrounding the No Surprises Act may not apply to Medicare plans, the intent of the rule to provide advance notice of non-covered services applies to Medicare beneficiaries.

Luxury or Deluxe Orthotics Require Patient Acknowledgement

When the set fee schedule for a covered item is lower than the cost of the item, the patient may be responsible for the difference. Before billing for such items, the provider must consult the payer’s restrictions and/or requirements. In some cases, the payer will allow the provider to initiate the S1001 code (deluxe, upgrade item requested). Whether this code is allowed or not, patient acknowledgement must be obtained before providing the service and passing along the cost to the patient.

Navigating self-pay options requires your practice to establish policies, train staff through scripting, and offer clear financial guidelines to patients. Most of this can be handled by adding a Financial Report of Findings (FROF) to the provider’s Clinical Report of Findings. The next step in this module will provide more information on this process.