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
Proper Use of Code S1001- Luxury Item, Patient is Aware
Luxury Item – Patient is Aware
Providers that participate with various third-party payers often find that although verification confirmed coverage for orthotics, the allowable fee schedule agreed to by contract may be lower than the cost of the Durable Medical Equipment (DME) item dispensed. In the case of orthotics, for example, the fee schedule may allow $98/pair, but the orthotics cost $150/pair. The fee schedule doesn’t allow for even a minimal profit on this or any other fixed cost of the provider.
Participating providers may be able to use the HCPCS code S1001 – Deluxe item, patient aware (listed in addition to the code for basic item.) If appropriate and with advanced patient notice and agreement, the patient can opt for the higher level, luxury item (e.g., a Foot Levelers’ Orthotic) and agree to pay the difference between the allowed amount and the provider’s actually charged fee.
Every provider agreement is different; however, we believe that the components of the HIPAA Omnibus Updates published in 2013 clearly allow a patient to direct how a provider deals with the carrier. Figure 1 below is an example of a provider agreement with language explaining that an arrangement between a patient and the provider is permitted. This arrangement should allow the patient to use insurance benefits toward the total cost of the orthotics, then, with agreement upfront, pay the difference between that amount and the provider’s actual fee.
Fig. 1
If you want to consider occasionally using the S1001 billing option, we recommend taking the following steps:
-
- When verifying orthotics coverage with the orthotics verification form, confirm the allowed fee for the item, if possible. Always ask about coverage for S1001 during verification in case it’s necessary to utilize this strategy for your patient to obtain some benefit for the orthotics.
- Check with your Provider Relations Department for any carriers with which the provider has a contract. Find out whether S1001 usage is addressed in the agreement or in the medical review policies. If possible, get all the answers in writing.
- Consider writing to the Provider Relations Department to request an amendment to your agreement with them to permit billing for upgraded products that include advanced-notice cost-sharing with the patient. A letter with sample language can be found in this module.
- Create an Advanced Notice document for the patient to sign. Outline the details and include the circumstances, the products, and the costs. Have this available for your patient to review and okay prior to charging anything above the allowed amount and billing the S1001 code to the carrier. A sample Acknowledgement to Self-Pay form is available in this course in the sample forms provided. (Keep in mind that some payers have their own Advance Notice document, check online first)
- Submit the billing to the carrier using the correct HCPCS codes and amounts as in any other billing situation. Include the S1001 code on the same date of service with a .00- or .01-dollar amount charged (this amount depends on the requirements of your software or electronic billing service). See Figure 2 below for an example.
- Collect the correct amount from the patient reflecting the difference between the actually charged fee and the amount paid by the carrier.
Fig. 2