Managing Tricky or Unusual Billing Situations

Overcoming Obstacles to Care

As with all financial aspects of care and treatment, sometimes prescribing functional orthotics for your patients doesn’t align with their health insurance coverage or an in-network agreement the provider is bound to follow. This page covers several scenarios that are commonly encountered by practices when ordering and dispensing functional orthotics.

Your Patient’s Insurance is Medicare Part B

Medicare Part B has specific rules for limited orthotics coverage through their Durable Medical Equipment (DME) benefits. Orthotic inserts are covered by Medicare only when placed in a shoe attached to a brace. Foot Levelers functional orthotics are usually not placed in a shoe attached to a brace, and, therefore, are a non-covered service under Medicare. Dispensing providers must have a registration with Medicare to bill as a DME supplier and received a prescription from an authorized provider. Chiropractors may not order or deliver these types of equipment under their own prescription through Medicare DME.

When services are excluded under Medicare, such as orthotics ordered by a Chiropractor, the patient is responsible for the full fee for the item or service. Providers should follow their usual Voluntary Advance Beneficiary process for advance notice using whatever form is in place in the office. The patient can and will pay for these important functional orthotics.

If your Medicare Part B patient has true secondary insurance that might cover Medicare excluded services, it’s critical to verify whether the payer needs a denial letter from Medicare Part B DME. Unfortunately, this is difficult, since, in order to file a claim, the provider must be a registered DME supplier. Often, Medicare will decline to issue a denial through the Part B carrier. Patients must reach out to their true secondary payer to explain this unusual situation and seek advice on how coverage may be available.

Your Patient’s Insurance is Medicare Part C (An Advantage/Medicare Replacement Plan)

It’s estimated that 47% of Medicare enrollees have opted for Medicare Part C over traditional Medicare Part B. This branch of coverage has three classes of policy types: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Private Fee For Service (PFFS). Before any decisions can be made about coverage, complete a thorough verification of benefits to see which plan the patient has chosen. From there, benefits are divided into those that must be delivered within the plan and what options the patient has for out of network benefits.

For that reason, we urge you to verify benefits the same as you would with any other payer class. As with Medicare Part B, there may be no clear path to coverage when orthotics are ordered or dispensed by a Chiropractor. These patients are unlikely to have any benefit for orthotics under their plan.

The Provider is In-Network and the Allowed Fee Schedule is Lower Than the Cost of the Functional Orthotics

Many payers have a fee schedule for functional orthotics that will not cover the cost of the quality items you provide. But there are solutions that allow you to supply the higher quality custom orthotics from Foot Levelers while not running afoul of your network agreement.

Under some plans, the payer will authorize providers to offer an upgraded item of covered DME, provided that the insured patient agrees to be responsible for the difference between the charge for the upgrade and the payer’s payment amount for the standard item. An upgrade usually consists of an item that includes an “excess component.” An excess component is an item, feature, or expense for an item or feature that is in addition to or is more extensive or more expensive than the item that is covered under the payer’s coverage requirements. In this case, Foot Levelers functional orthotics have enhanced benefits that apply to the recommended orthotics, such as the leather composition, the increased Zorbacel for extra shock absorption, and the three-arch support.

Healthcare Procedure Coding System (HCPCS) billing code S1001 describes a deluxe/upgrade item requiring a patient waiver. It allows a participating provider to supply an upgraded product under specific circumstances at the patient’s request. Certain carriers may allow for billing of this code, thus allowing for the patient to pay the difference up to the full retail price of the functional orthotics. An outline of the process, along with billing examples can be found in this module.

The Patient’s Case is a Personal Injury or Worker’s Compensation Claim

Often the diagnoses for which the provider is treating an injury are not in line with the required diagnoses for functional orthotics. Covered services for injury claims are usually medically necessary when the condition treated is a direct result of the accident. Because the usual clinical indications of functional orthotics tend to be issues that were pre-existing to an injury, it’s difficult to get coverage through accident claims.

However, the provider may feel strongly that the functional orthotics will make a difference in the patient’s condition. We suggest that you consider requesting pre-authorization for the orthotics in these instances. Reach out to the adjuster or claim representative and find out how to seek pre-authorization and what’s required for submission. A letter of medical necessity, linking the condition to the accident, or the recovery of the patient may be considered. A sample letter for pre-authorization is included in the sample letter collection provided in this course.

The Patient’s Diagnosis for Which Orthotics are Prescribed is not Covered by the Payer

It’s found that the need for functional orthotics is clinically appropriate for your patient. Upon verification, the patient’s payer has a Medical Review Policy that does not ordinarily cover the diagnosis for which the orthotics were prescribed.

If functional orthotics will not be covered by the patient’s benefit package, or if the service is considered to be for the patient’s comfort or convenience, the items won’t meet the medical necessity requirement for reimbursement by the carrier.

In this scenario, the patient is compelled to pay for the service out of pocket. Check the patient’s policy and/or your provider contract to ensure your ability to pass the fees on to the patient. Obtain written proof of the advance notice signed by the patient either on your generic form, or one that the patient’s payer requires. A template is provided in the samples collection in this course.

The lack of third-party coverage does not negate the necessity of functional orthotics for your patient. Most patients will pay cash for their functional orthotics if they understand their importance in the recommended treatment plan. If you are a member of a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA, you may be able to set a legal, discounted fee schedule for orthotics through such a plan. Remember, the No-Surprises Act of 2022 may require the delivery of a Good Faith Estimate (GFE) when patients are self-pay or not using their insurance in the practice.

Billing Orthotics to Third-Party Payers

Identify & Follow the Requirements

Practices that dispense and bill Durable Medical Equipment (DME) to third-party payers must pay close attention to the billing requirements of the carrier being billed as they often vary from carrier to carrier. Several factors come into play when billing directly to third-party payers:

    • What diagnosis codes are considered medically necessary, and therefore payable, according to the carrier’s Medical Review Policy (MRP)? Is the diagnosis/condition the doctor assigned for your patient included?
    • Are the billing codes that describe the orthotics your office dispensed listed in the MRP as covered billing codes?
    • After verifying the patient’s third-party coverage, are orthotics a covered benefit? If so, how often can they be dispensed and paid for by the carrier?
    • Will the carrier pay for more than one pair of orthotics in a period of time?
    • Do you know the allowable fee for the orthotics according to the provider fee schedule? If so, is it going to cover the cost of the orthotics?
    • Does the carrier you’re billing require that a certified DME provider or company bill all DME? If so, are you considered this type of provider? If not, there may be no coverage for the patient for DME dispensed directly by the doctor.

In general, there is no additional code to bill for the foot scan. The scan is usually conducted on the same date as any other Evaluation and Management (E/M) service. If it isn’t, the cost is bundled into the cost of the orthotics themselves in most cases.

Billing orthotics on your CMS-1500 billing form is not very different from billing other services. Figure 1 shows an example of the billing section of the form and how it might look if billing, along with the other services from the initial visit. Notice that one pair of customized, functional orthotics was prescribed and ordered for a total actual fee of $300 for the pair. The bill includes both the left and right orthotic, and each line item represents one unit of the pair. Pay special attention to the diagnosis pointing in box 24E of the billing form, identifying only the diagnoses that apply for the service rendered.

(Example provided for educational purposes only)

Fig. 1

You can review the sample initial visit documentation for this sample date of service by clicking HERE.

If the carrier’s allowance included coverage for two pairs of customized, functional orthotics and each pair costs $300.00, Figure 2, below, illustrates how billing might differ. Notice that each line item represents two units each for the left and right orthotic, for a total of two pairs.

Fig. 2

It’s important to understand the meaning of a Medically Unlikely Edit (MUE). An MUE is a Medicare unit of service claim editapplied to healthcare claims against a procedure code for services rendered by one provider/supplier to one patient on a single day. An MUE for an HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Commercial carriers sometimes use these edits to screen for unlikely circumstances that should not be paid (e.g., It may be unlikely to dispense two pairs of orthotics to the same patient on the same day.) The edit might capture the service and automatically deny it, but if the coverage has been verified, and it allows for two pairs, and they are medically necessary, don’t hesitate to appeal the denial. The documentation in the patient’s clinical record should reflect the medical necessity for more than one pair and outline the details needed to justify the order.

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.  

Mapping Your Charges

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Medicaid Reference Documents

Download Reference Documents Most of the resources a clinic will need can be found on the dedicated Medicaid website for their state. Listed below are some resources developed by CMS that can assist with understanding key aspects of the Medicaid program. How to Use the Medicaid National Correct Coding Initiative (NCCI) Tools Medicaid Provider Enrollment…

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Coding Therapeutic Exercises – 97110

97110 Description Description CPT code 97110, therapeutic exercise, is described as a therapeutic procedure-each session 15-minutes long—that treats one or more areas. The exercises are used to develop a single-exercise parameter that includes strength, endurance, range of motion, and flexibility. These activities are performed one-on-one with the patient. This code represents a distinctly separate and…

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