New Evaluation Codes and Orthotic Assessments

March 13, 2017
Rick Gawenda

With the implementation of the new physical and occupational therapy evaluation codes with dates of service on and after January 1, 2017, I am receiving many questions what do I think is the proper billing when a patient is referred to either 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 orthotic.

First, we need to provide the CPT code and description for orthotic management and training. Per the American Medical Association (AMA), CPT Professional Edition, 2017, CPT code 97760 is defined as follows: “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”. In the February 2007 edition of CPT Assistant, the AMA further states

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  1. If you are only billing the 97760 code to a Medicare patient, do you need to enter G-codes?

  2. We are a private practice with a DME supplier number. Patient had a full evaluation visit. We ordered a silver ring splint and dispensed to the patient at a later date. Can we also charge 97760 on the same day we dispensed the DME for the 15 minutes spent instructing the patient in wear/care/precautions, donning/doffing, daily wear and how to use the splint?

    1. We must make sure we use the proper language. Physical and occupational therapists provide orthotics. If you billed an evaluation CPT code and/or L code for an orthosis and also provided education and training, the education and training would be billed under CPT code 97760 in 2017. What combinations of CPT codes insurance companies pay for when done on the same day is insurance carrier specific and you would have to check.

  3. Great information Rick. So, if working in a CORF, you could bill using the L-code OR the 97760 for the assessment, fabricating and fitting of the orthosis… correct?
    If a 1 time visit only for the assessment, fabrication and fitting of the orthosis, do you also need to complete a POC for these patients? Thank you.

    1. Since you are a CORF, you could bill the L code for the orthosis for a Medicare beneficiary. Once you bill a treatment CPT code (97760), a signed plan of care would be required.

  4. How would you recommend billing for serial casting? Would this best be coded as NMR because the primary goal would inhibition of tone?

  5. Sorry for all of the questions. So a CORF, Rehab agency or Part B at. LTC facility can bill using either the L code or code 99760 when assessing, fabricating and fitting a patient for an orthosis? Either method woul be considered acceptable?
    Thank you.

    1. Possibly! It would depend on the insurance, the specific situation, perhaps your state practice act and lastly, what does the patient need and what is being provided by the therapist.

  6. We are billing using the L Codes but do realize some payers do not reimburse for these codes. In these cases, would it be ok to bill using 97760 for the orthotic assessment, fabrication and fitting time to these payers that do not reimbursement for the L Codes?
    So, can we use the L codes and 97760 both when billing for orthotics based on the payer?

    1. CPT code 97760 can be used for assessment, fitting and training. The assessment can include assessing the patient as it pertains to the need for the orthosis. This code is used for the initial orthotic(s) encounter. It may also be appropriate and applicable to bill for an evaluation. If you did, then the 97760 would be for the assessment for the orthosis, fitting and training.

  7. Hi Rick, I have a question regarding the new orthotic fitting & management codes. During the course of treatment is there ever an instance where you would bill the initial code a second time? For example, the patient on visit 1 is fitted with a custom static wrist cock up orthosis and then on the 6th visit receives orders to fabricate patient with a dynamic wrist/finger extension orthotic. Since this will be a new orthosis can you bill the initial code again?

  8. Can a PTA or COTA perform the orthotic fitting and charge the 97760 CPT code? Would a Therapist have to co-sign for them to charge this code?

    1. That is a question you would want to ask your state board if you are asking if an assistant can do an assessment for an orthosis.