Prosthetic Training: What’s Included in CPT Codes 97761 & 97763
For those of you that work with patient’s who have had a lower and/or upper extremity amputation and now must be fitted and trained in the use of a prosthesis, we do not fully understand what interventions, training and education we provide that are included as part of prosthetic training (CPT codes 97761 and 97763). In this article, I will teach you what services and interventions you provide are included in prosthetic training and provide you with a critical reference to support my answer that you will want to have at your disposal to educate insurance carriers and/or to use to support your billing of prosthetic training if being audited or reviewed by an insurance carrier.
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Per the American Medical Association (AMA), CPT code 97761 is defined as “Prosthetic training, upper and/or lower extremities, initial prosthetic encounter, each 15 minutes”. CPT code 97763 is defined as “Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes”.
So what services provided under a physical or occupational therapy plan of care would be considered prosthetic training and billed under 97761 for the initial prosthetic encounter or 97763 for the subsequent prosthetic encounter?
According to the AMA
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Rick, if this is the first time a PT is seeing this patient, should they also charge for an initial evaluation in addition to 97761 if they are assessing areas outside of the prosthetic need? Thanks for this very helpful article!
In my opinion, you would need to perform an evaluation first prior to implementing any treatment interventions.
Thanks for the info, this is timely for us. We are having an insurer consider 97112 as inclusive to 97763 as well. We did not interpret it that way with the CCI edits, but looks like that could valid as well under these definitions? Thanks, Krista
Rick,
Thank you for the article. I know by the title of it you were concentrating on the prosthetic portion of the codes 97761 and 97763, but could you also give examples for the orthotic side of the codes? Thank you, Linda
On my website, in the search box (magnifying glass near top right), type in 97760 and there are articles out on my website about orthotics.
Hi Rick,
Maybe I word the last question wrong. We provide upper limb prosthetics. The patient is referred to us and we make the prosthetic and then of course fit the patient and train. How would I bill an eval code along with all the L codes. I do not think I can actually do this I am just checking in.
You make a prosthetic for an upper extremity amputee? Or did you mean you make an orthotic?
I have another question for you. When billing L codes for the device are we able to also bill the 97761 for training of the prosthetic?
Thanks so much I really appreciate your help.
Training is not included in the reimbursement of the prosthetic and would be billed under the applicable CPT code.
If a hand therapist (PT or OT) is seeing a Medicare patient can they bill 97761 or 97763 on the same day as the eval?
Please refer to the latest version of the NCCI Edits as well as read the 2020 NCCI Policy Manual and section applicable to PT and OT services.
https://gawendaseminars.com/medicare-cms-cci-edits/
i am having an issue with this. they are saying if its done by OT only i cannot charge eval and 97763. even with a modifier
That is correct as the same discipline can’t bill those codes on the same day.
Can prosthetist tech use cot code 97761 or 97763? For trining and assessment of prosthetic for lower extremities.
Thank you in advance.
For Medicare, no. For all other insurance carriers, I would also say no.
How do these codes apply to the fabrication of temporary orthotics, custom hand splints, or other orthosis supplied in a free standing OP private clinic? Are these considered DMEs and subject to exclusion if the private clinic is not a licensed DME provider or are they considered custom orthosis as indicated in the POC as medically necessary to treat the patient’s condition
This article focuses on prosthetic training. For orthotics, you can read my L Codes for Orthotics FAQs as well as search for articles on orthotics, 97760 and 97763 under Current News.