Wiki Custom Orthotic Coding Assistance

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amieras

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Grand Rapids, MI
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Hi All,

I am hoping to get some advice on what HCPCS and CPT are appropriate to bill for casting/ordering/fitting a custom orthotic. We currently bill L3000 and cast via a digital image. Is there an appropriate casting code that is allowed for this method?
 
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Hello there!
We bill 29799 bilateral for the casting whether it is manual or digital. Not all payers cover it, but many do. Then at the time of dispense, bill out the L3000 RT, L3000 LT. With the exception of Medicare, which does not cover custom orthotics.
 
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@podcoder70 Do you have any knowledge of an ICD-10 code that can be used when billing bilateral orthotics but the provider is only treating one side? I have a provider who pretty consistently likes to bill bilateral orthotics out with only a right or a left DX code. I am told by the provider that they are only treating the one side and that there is not DX code for the other. We have attempted to appeal with payers but they usually are upholding their denials due to invalid DX.
 
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Amberjo87 said:
@podcoder70 Do you have any knowledge of an ICD-10 code that can be used when billing bilateral orthotics but the provider is only treating one side? I have a provider who pretty consistently likes to bill bilateral orthotics out with only a right or a left DX code. I am told by the provider that they are only treating the one side and that there is not DX code for the other. We have attempted to appeal with payers but they usually are upholding their denials due to invalid DX.
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Unfortunately, there is no ICD10 code specific to this situation. Coverage for orthotics depends on the payer. For example, Medicare and Medicare Advantage plans do not cover them, neither does UHC, Aetna has limited coverage for very specific diagnoses, and Cigna is a big question mark. Blue Shield and Anthem are plan-specific. The assumption of coverage is for bilateral as it would be inappropriate to dispense unilaterally as it would throw off the patient gate and cause new medical issues. An appeal needs to be sent with a letter of medical necessity explaining why the patient requires bilateral, you have to educate the payer on why their denial is wrong. For the denials you received, who was the payer?
 
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podcoder70 said:
Unfortunately, there is no ICD10 code specific to this situation. Coverage for orthotics depends on the payer. For example, Medicare and Medicare Advantage plans do not cover them, neither does UHC, Aetna has limited coverage for very specific diagnoses, and Cigna is a big question mark. Blue Shield and Anthem are plan-specific. The assumption of coverage is for bilateral as it would be inappropriate to dispense unilaterally as it would throw off the patient gate and cause new medical issues. An appeal needs to be sent with a letter of medical necessity explaining why the patient requires bilateral, you have to educate the payer on why their denial is wrong. For the denials you received, who was the payer?
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There have been multiple but Blue Cross and a couple Medicaid products. Thank you for your explanation. I had not found a DX code and we have been appealing these denials but I just wanted to see if there was something out there to help combat the denials.
 
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podcoder70 said:
Hello there!
We bill 29799 bilateral for the casting whether it is manual or digital. Not all payers cover it, but many do. Then at the time of dispense, bill out the L3000 RT, L3000 LT. With the exception of Medicare, which does not cover custom orthotics.
Click to expand...
Hi, this is the documentation for when the patient is scanned for their custom orthotics at our office:

"Patient would benefit from custom orthotics. Due to the unique foot structure the patient, a custom orthotic will intimately contour and contact the foot aiding in support of the foot and prevent pathologic motion. This will allow the patient to ambulate for longer distances and prevent pain due to the pathologic motion. With this, the patient will be able to perform activities of daily living in an improved fashion without pain.
Patient was scanned today for custom orthoses with the Forward Motion 3-D mapping software. A full 3-D image was obtained with all necessary structures in full view.
The necessary adjustments to the orthosis will be applied to the orthosis based on the patient's structural and biomechanical deformity. Patient was instructed on the appropriate wear-in protocol and respective time period to allow the feet to adjust to the orthotics.
Informed the patient that the orthotic would be made for her foot by the company. They will send the orthotic to us within 2-3 weeks. At this time, the patient will be informed that the orthotics are ready for pickup. Instructed patient to make a follow-up appointment at that time for 4 weeks. At this time, we will assess the patient's the effectiveness of the orthotic and adjusted as necessary."

Would I be able to bill for the 29799/S0395 during this encounter or is this bundled into the L3000? Also, What percentage would I calculate for the fees for the scanning?

Thank you!
 
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