How to Bill for an Orthotic Evaluation or Assessment

February 5, 2021
Rick Gawenda

I am receiving many questions regarding what is the proper billing when a patient is referred to either outpatient physical therapy or occupational therapy for the purpose of an orthosis. In this article, I will answer this question from 2 perspectives. I will first address when a patient is referred for a one-time visit for an orthosis and secondly, provide the answer for when a full evaluation is required to develop the appropriate treatment plan in addition to an assessment related to determining the specific orthosis required for the patient.

First, we need to provide the CPT code and description for the 2 orthotic management and training CPT codes. Per the American Medical Association (AMA), CPT Professional Edition, 2021, CPT code

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  1. Hello, our company is not Medicare licensed as DME provider. However our rehab department provides custom fit orthotics requiring expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. For example, short arm splint application as described in CPT 29125 provided along with training, including wear and care of the orthotic. Could we bill this as 97760, 29125-59. How do we bill for the supply?
    Do private payers also require that we have Medicare DME license?
    Thank you in advance for the clarification!

  2. Hello,
    If we receive a case from a home modification company that’s already been billed for an IE – would we then take over the case and not do an IE? Or would we then just do our own IE and bill for it as well?
    Thanks in advance!!