Vol. 16 Issue 1
Deciding on the right code for splint fabrication?
Q: Many therapists are debating whether to use L codes or CPT code 97760 for splint fabrication. Can you tell me the correct way to go? I realize L codes encompass materials, labor and revisions. My concern is reimbursement for materials using the 97760 code. Historically, this has been a supply code.
A: The answer depends on the insurance carrier, and if the carrier reimburses for L codes billed under a physical and/or occupational therapy plan of care. Providers of therapy services who submit claims to fiscal intermediaries under Medicare Part B benefits can bill and be reimbursed for L codes without requiring a durable medical equipment (DME) license. Providers include hospitals, comprehensive outpatient rehab facilities, outpatient rehab facilities, skilled nursing facilities and home health agencies that provide outpatient therapy services at home. Providers can bill for the appropriate L codes on the UB-92 claim form, along with other therapy services they're billing during that claim period.
Suppliers of physical and occupational therapy services provided under Medicare Part B benefits require a DME license in order to bill and receive reimbursement for custom fabricated orthoses. If they have a DME license, they can submit the claim for L codes to the durable medical equipment regional carrier on a 1500 claim form. Regarding non-Medicare payers, suppliers and providers of therapy services must verify if the insurance company reimburses for L codes and bills under a therapy plan of care, and if the supplier or provider has a DME license.
CPT code 97760 was a new CPT code in 2006; it's not a supply code. The description for 97760 is: Orthotic management and training (including assessment and fitting when not otherwise reported), upper extremity, lower extremity and/or trunk, each 15 minutes. Management may include assessing the patient for need and type of orthosis, range of motion measurements and manual muscle testing, assessing sensation and grip strength testing. Management also may include the design, fabrication and fitting of an orthosis. In addition, code 97760 includes the training provided to a patient regarding use of the orthosis during activities of daily living and other functional activities.
If a supplier or provider bills for an L code, they only bill the appropriate number of units of 97760 for the time spent on the training component; the L code reimbursement includes the assessment, design, fabrication and fitting time, and supplies used to fabricate the orthosis. If an insurance carrier doesn't accept L codes from a supplier or therapy provider, these entities can handle billing under code 97760.
L codes reimburse better than the appropriate number of units of 97760 for assessment, design, fabrication and fitting time. L codes describe the type of orthosis that a physical or occupational therapist fabricated for the patient. Suppliers and providers of therapy services should always bill the codes that best describe an intervention, regardless of reimbursement, and make sure documentation supports the billing of their codes.
Rick Gawenda, PT, is director of physical medicine and rehabilitation at Detroit Receiving Hospital in Michigan. He conducts national seminars on coding and reimbursement, along with other topics. If you have a tough coding issue you can't crack, e-mail firstname.lastname@example.org. To read more coding suggestions, go to www.advanceweb.com/REHAB and click on the Coding Clues tool bar.