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.


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:

    1. 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.
    2. 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.
    3. 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.
    4. 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)
    5. 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.
    6. Collect the correct amount from the patient reflecting the difference between the actually charged fee and the amount paid by the carrier.

Fig. 2


Orthotics Verification Form & Training

Watch this tutorial to understand the intent behind the specific questions we recommend when verifying third-party coverage for custom orthotics. Download, review and save this customizable tool to reference as you learn the reasoning and recommendations behind performing specific orthotics verification. Put this form into practice when verifying coverage in your office. Review the sample to see how to use the form.

Download Support Tools

Download, review and save this customizable tool to reference as you learn the reasoning and recommendations behind performing specific orthotics verification. Put this form into practice when verifying coverage in your office. Review the sample to see how to use the form.

Customizable Orthotics Verification Tool
Customizable Orthotics Verification Tool-Example

Coverage & Benefits Considerations

Just because someone has insurance coverage for other healthcare, there is no guarantee that coverage is available for Durable Medical Equipment (DME) like custom orthotics. And then, even if there is orthotic coverage, there may be restrictive limitations on the conditions for which orthotics may be prescribed. Sometimes, the payer requires DME to be dispensed by a licensed DME supplier to be a covered benefit. This overview tutorial calls attention to the most important considerations when reviewing coverage for your patients for the potential coverage of custom orthotics through their health plan. It also includes a demonstration on how to find the Medical Review Policy for orthotics, if one exists. Download and refer to the sample Reference Document which is an example of the details in some payers’ Medical Review Policy for orthotics.

Download Reference Document

Sample Medical Review Policy (MRP) for Orthotics


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