Frequently asked questions about billing orthotics

CPT® codes for orthotic and prosthetic management and training can be used for orthotic evaluation, selection, fabrication, and training.

97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.

97761 - Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes.

97763 - 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.

97760 and 97761 are utilized only for the first visit in which orthotic or prosthetic assessment and fitting are completed. Supplies can be billed with 97760 and 97761 if an orthotic is fabricated.

97763 should be used for all subsequent encounters for modifications, fitting adjustments, and additional training regardless of whether the orthotic is custom-made or prefabricated.

Remember, these are time-based codes. More than one unit can be billed based on the amount of time spent face-to-face with the client. Also, these services must be properly documented to include not only time spent but what was fabricated, adjusted, or trained; the reason for the fabrication, adjustment, or training; activities or exercises performed in the orthotic; a description of the client’s condition; and the client’s response.

“Off-the-shelf” and “custom-fitted” orthotics are both prefabricated, meaning that the orthotic is manufactured in quantity without a specific beneficiary in mind. An orthotic is considered prefabricated even if it is assembled in the clinic from prefabricated pieces.

• Off-the-shelf orthotics require minimal self-adjustment prior to issuing to a client.
• Custom-fitted orthotics require expert fitting which can include trimming, bending, and molding to a specific client's needs. Documentation for custom-fitted orthotics must clearly indicate what was modified, why it was modified, and why the modifications required an expert such as an occupational therapy practitioner to complete.

"Custom-fabricated" orthotics are orthotics made from raw materials for a specific client. Custom fabrication of orthotics or prosthetics involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc.

If the orthotic is not fabricated on-site, it will most likely have an appropriate L code for billing. Some practitioners will send the client to a supplier who will bill Medicare directly for the orthotic. Others may choose to keep a supply of these orthotics in the therapy clinic and bill Medicare when they are dispensed. If billing an L code for the orthotic, 97760 and 97761 should only be used for the initial orthotic or prosthetic encounter when training is completed during that encounter and training alone exceeds 8 minutes. Payment for fitting a custom-fit orthotic is included in the L code and should not be separately billed.

Orthotics and prosthetics fall under Medicare's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) rules. In order to bill DMEPOS to Medicare, you must apply for a separate DMEPOS number. This is in addition to your National Provider Identifier (NPI) and Medicare Provider Transaction Access Number (PTAN), which allow you to bill for covered occupational therapy services as a health professional. To apply for a DMEPOS supplier number you must complete Form 855S. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855s.pdf

Private insurance may have different policies and a separate claims address for DMEPOS claims. Check with the insurance carrier for their specific DMEPOS policy.

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity of the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information, as applicable, such as duration of the patient’s condition; clinical course (worsening or improvement); prognosis, nature, and extent of the functional limitation; other therapeutic interventions and results; and past experience with related items.

CGS, a Medicare Administrative Contractor (MAC) who reimburses for DMEPOS such as orthotic devices, provides guidelines for documentation which can be found on their website.

Medicare has two DMEPOS Medicare Administrative Contractors (MACs) that handle different regions of the country. The carriers and their websites are listed below.

NORIDIAN

DMEPOS MAC Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia)

DMEPOS MAC Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)

https://med.noridianmedicare.com/web/jadme/policies/clinicians-corner

https://med.noridianmedicare.com/web/jddme/policies/clinicians-corner

CGS

DMEPOS MAC Jurisdiction B (IL, IN, KY, MI, MN, OH, WI)

DMEPOS MAC Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)

https://www.cgsmedicare.com/jb/mr/phys_corner.html

https://www.cgsmedicare.com/jc/mr/phys_corner.html