In last weeks article, I discussed two options for the billing of an orthosis to the insurance carrier, including the Medicare program. Those options were either the applicable L code for the orthosis or CPT code 97760 (orthotic management and training) for patient’s under an outpatient therapy plan of care. In this weeks article, I will discuss what practice settings can bill L codes to the Medicare program for orthotics provided under an outpatient physical or occupational therapy plan of care without requiring a durable medical equipment (DME) supplier number, which practice settings do require a DME supplier number to bill the Medicare program for orthotics using L codes and how to bill orthotics to private insurance carriers, workers compensation programs and state Medicaid programs.
Lets start with the Medicare program. If you are an Outpatient Rehabilitation Facility (Rehab Agency), Comprehensive Outpatient Rehabilitation Facility (CORF), Skilled Nursing Facility (SNF) providing Part B therapy services or an outpatient hospital therapy department, you do
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Can a hospital based outpatient therapy department obtain a DME supplier number? If yes, how?
The hospital would have to obtain the DME supplier number. Here is the link to the CMS DME page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/index.html
Thank you Rick, for this insight. Our private outpatient clinic has a growing hand caseload, including Medicare. Will you please give some insight as to the pros/ cons of becoming a DME provider for Medicare reimbursement?? I have heard you speak at several PPS and APTA conferences, and feel there may be some risks involved.
Thank you and I look forward to your comments!
I only speak, write and consult on outpatient therapy services. I do not provide consulting services in the area of becoming a DME supplier or not as there have been many changes over the last several years due to the competitive bidding process CMS implemented. I hope you enjoyed the 3-part series on orthotics.
If a pt. returns with an orthotic and you assess it and determine a new one is needed, but the item is not seen by medicare as an orthotic due to not having ridged parts (It’s a soft posey used to prevent skin breakdown in someone with advanced contractures due to CP) and you educate the pt. on this and where they can purchase this on their own, what would you bill?
With the correct documentation, my opinion would be CPT code 97535 (self care/home management).
Hi Rick, Can L-codes be billed in an inpatient setting? Is this determined by payment status indicator? I see prosthetic and Orthotic falls in status indicator “A”. Any feedback you can provide is greatly appreicated.
in the inpatient setting, L codes would be included in your DRG payment under Medicare and would not be separately payable.
If you see a patient in an outpt hospital setting for first visit and charge an L code for orthotic assessment and fabrication, what is the correct code to use if you need to modify the orthotic on the second visit?
Since you billed the L code for the initial orthotic encounter, if the patient required additional training, that would be included under CPT code 97763. Minor adjustments would be included in the payment for the L code.
ASHT referred to a change in Medicare that does not allow L code billing if an outpatient hospital does not have a DME license. I am having a hard time extracting whether you can or can’t do this out of the latest version of Medicare Policy manual. Do you have any resource suggestions or knowledge of this?
I would recommend you contact ASHT and ask for their reference.
I just started getting denials from MassHealth for Custom made orthotics – did something change? We are a hospital outpatient rehab dept without a DME license.
MassHealth is not the same as the Medicare program. You would need to look at the denial reason(s) you are receiving from MassHealth. MassHealth could require you have a DME supplier number.
How do you obtain a DME number? Is this usually required in billing Anthem for the L codes in your experience?
You can learn about obtaining a DME supplier number by clicking on the link below.
I work in an outpatient hospital setting. My question is why and when would I bill an “L” code for fabricating an orthosis versus billing 97760? I have always billed 97760. Is this wrong?
I would suggest you read my FAQs on L codes as well as search Current News for all the articles that I wrote on L codes that will answer your question.
We are an Outpatient Hospital based Rehab department. We are currently treating a patient with Humana, diagnosis of Right foot pain. We billed the L3030 code x 2 for orthotic fabrication for bilateral feet. Humana is denying the payment, saying there is not a correct modifier to go with the code. Is there a modifier we need to apply that justifies fitting both feet as opposed to just the Right? Or a different modifier of some sort that we need to apply in order to cover the cost of the orthotic insert? Any help would be greatly appreciated!
It’s difficult for me to answer. You may need to bill L3030 for 1 unit on one line item and attach modifier RT to that code and on a separate line, bill L3030 again for 1 unit and attach modifier LT to that code.
If we have a supplier (for OTS back braces) do we bill the L codes or the 97760? for the fitting and instructions given to the patient the day we dispense the brace in the office.