Very often, third-party payers allow for a fee schedule that is lower than the cost of functional orthotics. Participating providers run into difficulty when ordering custom orthotics because the quality is so much higher than the fee schedule allows for. In this case, you may be able to have the patient “opt-in” to the higher cost orthotics, agreeing to cover the overage. This Fact Sheet outlines the process for S1001, and considerations that must be taken into account. Additionally, since January 2022, these costs would also be included on any required Good Faith Estimate in conjunction with the No-Surprises Act.
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Proper Use of Code S1001-Luxury Item, Patient Aware
When patients must pay cash for products and services in the practice, it is convenient to offer several options. This Rapid Tutorial outlines your options and demonstrates how these options can fit best into your practice.
Many of the service codes that are ancillary to dispensing functional orthotics call into the realm of Physical Therapy Procedures. Many of these services are coded based on time. Download and review this Fact Sheet for a refresher on how the timed coding rules are to be followed.
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Guidelines for Timed Codes
Billing for functional orthotics can be tricky. Because you are prescribing and selling two separate items, they must be reflected on the 1500 billing form as such. Note there are two options for proper submission. Study this Fact Sheet for best practices on billing orthotics on the billing form.
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Billing Orthotics to Third Party Payers
Often, third-party reimbursement for orthotics hinges on extremity diagnoses or conditions of the foot. Sometimes, the Medical Review Policy (MRP) requires that findings are included in the medical record that point to specific diagnosis codes. This Functional Foot Examination is provided to supplement your documentation when ordering and dispensing functional foot orthotics. Feel free to download and save it, and use it when additional documentation is required.
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Functional Foot Examination
Verification of benefits without a review of the payer’s Medical Review Policy (MRP) is like peanut butter without jelly. It’s critical to know the specific coverage allowed and for which diagnosis codes benefits will be provided. It’s not always possible to receive reimbursement for functional orthotics that are prescribed for spinal conditions. This is a sample MRP. Download and review it, and then watch the video to see how to find the MRP for all the payers you work with and expect to bill for functional orthotics. Notice the diagnosis codes allowed, the conditions under which orthotics would be considered, and other important payer information.
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Sample Orthotic Medical Review Policy