Orthotics Provided Under a Therapy Plan of Care: Questions and Answers
One of the most common topics I provide consulting services to my clients on is in regards to how to bill for an evaluation for an orthosis. Unfortunately, there is not just one answer as my answer will depend on at least 2 factors; what is your practice setting and what insurance does your patient have. In this article, I will provide the answers to the most common questions I receive in regards to the billing for an evaluation for an orthosis under an outpatient physical or occupational therapy plan of care.
Question
What are L Codes?
Answer
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Question
Can a physical therapist (PT) or occupational therapist (OT) bill L codes to the Medicare program, commercial insurance carriers, workers compensation carriers and other payers of outpatient therapy services?
Answer
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Question
Does a private practice require a durable medical equipment (DME) supplier number to bill L codes to the Medicare program for orthotics provided under an outpatient PT or OT plan of care?
Answer
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Question
Does a non-private practice require a durable medical equipment (DME) supplier number to bill L codes to the Medicare program for orthotics provided under an outpatient PT or OT plan of care?
Answer
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Question
What is included in the payment of the L code billed for an orthosis provided under an outpatient PT or OT plan of care?
Answer
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Question
If we are a private practice and do not have a durable medical equipment supplier number, how can we bill the Medicare program for orthotics provided under an outpatient PT or OT plan of care?
Answer
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Question
What is included in the training component of CPT code 97760 or 97763?
Answer
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Question
Can I bill a L code and 97760 during the same visit for the same patient?
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Question
Can you provide an example when you would bill a L code and 97760 on the same date of service for the same patient?
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Question
Can I bill an evaluation code (CPT codes 97161 – 97163 and 97165 – 97167) on the same date of service that I also bill a L code (same discipline)?
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Question
What are the descriptors for CPT codes 97760 and 97763?
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Question
What is the difference between CPT codes 97760 and 97763 and when would I bill 97760 versus 97763 and vice versa?
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Question
To bill a L code to any insurance carrier besides traditional Medicare, does a private practice or non-private practice facility require a DME supplier number?
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I hope you found this article helpful and you now have a better understanding how to bill for an evaluation for an orthosis. Thank you for being a Gold Member!
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Excellent information. Thank you!
Comprehensive, thank you. Do you have a recommendation for billing the materials used for fabrication under 1500 billing?
CMS does not pay for materials.
If a patient comes in with an order for a splint we preform an Orthotics Training is a Plan of Care required to be signed off on by the physician and will the case require a Certification Period?
Is there a limit on the number of times a 97763 can be charged?
Under Medicare Part B, if billing any CPT codes other than an evaluation, a certified plan of care is required.
If an evaluation (97161) is performed to set up a plan of care with follow-up visits and an orthosis is fit and trained on same day, would you bill 97161 and 97760 for this date of service? Or does the evaluation code (97161) cover it?
The PT evaluation would not include the fitting and training and this would be billed under 97760 if it’s the initial orthotic encounter.
Hi
Do you think or have you seen an insurance deny a large number of units of 97760? We recently received a denial of 6 units of 97760.
Thanks
Karen McGIllin
You would need to look at your contract to see if there is a limit on the amount of units billed and paid per date of service.
I work in a multi-disciplinary private practice. We have a DMERC license and a DME department that will fit prefab items such as Post op splints. As a PT, we often spend 15 to 30 min making adjustments to braces and slings. We should bill initial encounter 97760. But if a different therapist within our practice were to make another adjustment. Would they bill a subsequent encounter or another initial encounter 97760 since it was the first time that provider made an adjustment…. Basically, is 97760 a patient specific code or a provider dependent code who share the same TAX ID but bill as private practice under each provider and servicing and billing provider. Thanks for the above information very helpful.
Would be subsequent since the same orthosis.
patient referred to therapy for foot pain and foot orthotics, PT performed initial eval (97161) , manual therapy (97140) and orthotic initial encounter (97760). PT established a POC with cert dates 1/5/22-3/5/22. Patient did not return after 2/16/22 visit until 4/19/22. Medicare automatically discharges after 60 days, so on the 4/19 visit PT should of billed an eval (?) and the appropriate orthotic code. What orthotic code is appropriate since an eval must be billed but patient received adjustments to initial orthotic since you can’t bill eval 97161 with 97763? Would you use 97161 and 97760 even though it is not the initial encounter for that orthotic?
Due to liability reasons, I do not provide consulting services in this format.
I am in a Physician owned practice and we have recently (starting in 2022) received denials from Medicare B, stating that our custom orthosis are same or similar to an off the shelf splint. For example: A patient received an off the shelf pre-operatively and our DME dept billed L3908. The patient ended up having surgery and needed a custom orthosis because of the positioning required. Our OT made a custom orthosis and billed L3906. I am aware of the same/similar in the 5 year time span for the same custom orthosis. However this is definetly not same or similar. The documentation was in place and we even submitted it for reconsideration, but the denial decision was upheld. We have many other examples as well.
It appears this is only happening in our Medicare B patients. Do you have any insight into this? Thank you
I recommend you contact the applicable MAC.
We are a hospital based outpatient therapy department. We do not have a DME license. At current our CHT OTs are making our hand orthotics and billing the L code.
We are also performing an OT evaluation and billing for it.
Is it necessary that we perform the evaluation or could we just be billing for the fabrication (L code).
Thanks
The L code payment includes the assessment time associated with the orthosis.
Hi Rick,
Can you confirm that I can bill out the L code and 97760 for the subsequent training and educational piece even if for a high temp orthosis such as L3906?
97760 is for the initial orthotic encounter and does include training. 97760 is not tied to any specific L code.