Orthopedic Coding Alert

The practice also reports these codes for the second visit:
 

"This practice seems to be grossly over-reporting the procedures they performed for the orthotics fitting and dispensing," says Ken Robertson, who bills for three podiatrists in Atlanta. Reporting orthotics codes can be very complicated, but submitting twice the appropriate number of codes isn't a good substitute for accuracy.

Report E/M, Not 95851, for First Visit

First, the practice reported both 99213 and 95851, but the National Correct Coding Initiative (NCCI) bundles 95851 into the E/M codes. Also, the November 2001 CPT Assistant advises, "The testing would be included as part of the physical examination, one of the key components used to determine the level of E/M service."
 
The practice should pare down its claims considerably by reporting 99213 for the initial E/M visit, but not 95851 for the range-of-motion exam.
 
If your orthopedist applied the plaster cast to create an orthotic mold, you should also exclude 29799 from your claim. You should report this code only if you apply the cast to immobilize the patient's foot.
 
As for the casting supplies, the December 1998 CPT Assistant states, "The fabrication of the orthotic is not recognized as a distinct service, but rather a provision of materials and supplies that may be reported with a supply/material code (e.g., CPT code 99070 or HCPCS Level II code)."
 
Even though CPT Assistant supports reporting the casting supplies, Robertson reminds practices that reporting the HCPCS supply code (A4580) probably depends on carrier variability.
 
Most orthopedic practices will therefore report only the E/M service and the casting supplies for the first visit.
 
99002 Bundles Into Other Services

When the patient returns for her second visit, you should not report 97504, 97703 and 99002, as the practice in our example billed its claim. Most carriers consider the orthotic fitting, training, handling and checkout part of the fee for the orthotic itself. If your carrier does not include these costs in the orthotic fee, you should select just one of these codes. The NCCI considers the fitting and training code, 97504, to be mutually exclusive to 97703, so you can never report them together. In addition, Medicare does not allow any payment for 99002, because this service is always bundled into payment for other services rendered on the same day.
 
To determine whether you should report 97504 or 97703, ask yourself whether you trained the patient or adjusted the orthotic.
 
You should report 97504 if you train the patient to use the orthotic, but placing an orthotic in the patient's shoe does not constitute "training" - you must actually work with the patient for at least 15 minutes, teaching her how to move appropriately with her new orthotic.
 
If you spend at least 15 minutes examining the patient during functional activities to ensure that the orthotic fits properly, you can report 97703. Remember, however, that if a therapist performs the training or adjustment services, you must maintain a therapy plan of care in the patient's chart, or you cannot report these codes.
 
If, during the second visit, the physician manages the patient's condition and performs an E/M service in addition to fitting the patient for her orthotic, you can report an E/M code instead of the fitting, training and checkout codes.
 
Most orthopedic practices will therefore report 97504, 97703 or an E/M code for the follow-up visit.

Bill Orthotic to DMERC

Most orthopedic practices cannot report durable medical equipment (DME) items such as an ankle-foot orthosis to their normal Medicare carrier. DME claims are instead routed through one of four Durable Medical Equipment Regional Carriers (DMERCs).
 
You can bill a DMERC directly only if you have a DME supplier number, says Richard C. Papperman, CHBME, owner of Cape Professional Billing, a medical billing service in Cape May Court House, N.J., that bills for four DME suppliers.
 
If a medical practice wants to dispense its own DME supplies, it could do one of three things, Papperman says. The first is to acquire a DME supplier number and bill the supply directly to the DMERC. You should be sure that you have fully documented medical necessity in the office notes. In addition, you should always follow Stark laws if you have a financial interest in the practice.     
 
The second option is for the DME supplier to bill Medicare for the orthotic costs. The supplier pays your practice fair market rent to store an inventory of DME supplies, or sends you orthotics on an as-needed basis. You forward the paperwork to the supplier, and the supplier directly bills the DMERC.
 
A third option is to give the patient a prescription and a certificate of medical necessity (CMN), and the patient picks up the orthotic at an independent dispensary. The local medical review policies (LMRPs) for all four DMERCs state, "Ankle-foot orthoses described by codes L1900-L1990 ... are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally." Once you're certain that your patient fits the DMERC's requirements, you should turn your attention to your CMN.

Concentrate on That CMN

"The questions on the CMN aren't hard, but if the form isn't completed correctly and the supplier doesn't look it over before dispensing the item, the product could be dispensed and then later rejected for payment by Medicare," Papperman says. "Unless the patient has already signed a properly completed advance beneficiary notice (ABN) stating that he will pay should Medicare deny the charge, then the DME item becomes free to the patient."
 
He reminds physicians that although they have to write prescriptions up-front for suppliers to dispense DME items, they have up to 30 days to fill out the CMN. "Even so," he says, "whenever possible, a supplier should not dispense anything, especially big-ticket items, without a properly completed CMN."
 
Remember that DMERCs maintain very rigid requirements for orthotic reimbursement, so if you are ever in doubt, always contact your insurer to confirm that your patient is a candidate for the orthotic you've prescribed.