DME FOR DPMS

Understanding Physical Therapy Codes

Many CPT codes are under-utilized by podiatrists.

BY PAUL KESSELMAN, DPM

his month’s article will extremity(ies) and/or trunk, initial or- especially important to note that the be thought-provoking and thotic(s) encounter, each 15 minutes) HCPCS L-codes address the provision perhaps even controver- 97761: Prosthetic(s) training, of the device itself as well as the fit- sial in discussing how upper and/or lower extremity(ies), ting and adjustments. The CPT codes codes underutilized by Tphysical therapists may or may not be used within your practice. It is up It is especially important to note that the 39 to the reader to determine whether the clinical circumstances and the HCPCS L-codes, address the provision of the device itself third-party payers’ policies allow for the payment of these physical thera- as well as the fitting and adjustments. py “training” codes. The three codes of particular in- terest for this month’s discussion are initial prosthetic(s) encounter, each will only address the training on the located in the Physical Therapy and 15 minutes) and use of the device and not the fitting Rehabilitation section of CPT Coding 97763: Orthotic(s)/prosthetic(s) and adjustment when you are the and address the provision of orthotic management and/or training, upper provider of these devices. devices. extremity(ies), lower extremity(ies), The Medicare AFO and Lower 97760 Orthotic(s) management and/or trunk, subsequent orthot- Limb Prosthetic (LLP) policies clearly and training (including assessment ic(s)/prosthetic(s) encounter, each state that the dispensing, fitting, and and fitting when not otherwise re- 15 minutes. adjustments are not separately pay- ported), upper extremity(ies), lower For the podiatric physician, it is able and are inclusive of the L-codes (e.g., custom fabricated devices). Some L-codes also include the fitting and adjustment as part of their narratives (many are custom fit) It is clear from these stipulations that the fitting and adjustment are included with the appli- ance both as per a reimbursement pol- icy and based on HCPCS code defini- tion. Thus the use of these three phys- ical therapy codes solely for fitting and adjustment, when you are the provider of the L-codes, is inappropriate. However, in the rare case when you are not the provider of (not bill- ing for) the orthotic/prosthetic, the use of these CPT codes would seem to be appropriate for the fitting and adjustment of the orthotic/prosthetic. A clinical example comes to mind where “a snowbird” presents to your © Stockbakery | Dreamstime.com Continued on page 40

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PT Codes (from page 39) foot orthotics to consider are: in the L-code. In that scenario, CPT ) 1 Footwear limitations for spe- 97760 and 97763 codes are not sep- office with an orthotic which was cific devices and activities. arately reimbursable. If the policy mailed to them by their local DPM. ) 2 Initial break-in wearing does not address those issues, then You are asked to fit the device. schedule. perhaps 97760/97763 codes may be In addition to billing the patient ) 3 Possibility of muscle fa- both appropriate and be separately an appropriate E/M visit, 97760 (for tigue based on new biomechanical reimbursable. the initial fitting), the coding of the positioning. CPT code 97761 for Medicare above PT codes seems to permit the Beneficiaries regarding Lower LLP assessment and fitting of the device Are these three issues a separate devices (e.g.,L5000) or for AFOs because you did not otherwise re- and distinct entity from the fitting with respect to CPT 97760 or 97763 port (bill) the DMEPOS device. Note that because there is no NCCI edit between an E/M code performed on CPT codes 97760-97763 are not only the same date as the PT codes, there should be no issues with being paid underutilized by podiatrists but by other for both the appropriate E/M service and PT service. health physical therapists, occupational therapists, Note that the L-codes do not spe- orthopedic surgeons, physical medicine, etc. cifically address the training of the patient on how to use their device(s). Exactly what is meant by training your patient on the use of the device? and adjustment of the foot orthot- may provide a different perspective. 40 When you fit and adjust a patient, is ics? Are the above questions too Anyone who has ever provided LLP the training on the use of the device oversimplistic or are there clinical or AFO services to a patient under- not a significant component of that scenarios (e.g., diabetic with foot stands that the training on the use service, or is training the patient on ulcer where an off-loading foot or- of these devices is far more complex the use of a device a separate and dis- thotic is dispensed vs. a functional than for foot orthotic patients. Train- tinctive service apart from the fitting foot orthotic for an average adult) ing on the use of an LLP or AFO may consist of patients being pro- vided with a minimum of four key issues: If you can document fitting and adjustment vs. training 1) Complex instructions on don- as separate issues, then one may consider the use ning (applying) and doffing (remov- ing) these devices. of these physical therapy CPT codes to be perfectly ) 2 Assisting them with shoe placement, purchase, and fitting of appropriate when providing foot orthotics. the device. ) 3 Instructions on how to per- form self-examinations for tissue in- and adjustment? Medicare’s AFO and which mandate a difference in your tegrity and monitoring for skin break- LLP LCD and accompanying LCA are response? down, irritation, etc. and noticeably absent of any clear lan- If you can document fitting and ) 4 Instructions on daily inspec- guage on training. The policy (written adjustment vs. training as separate tions of all the devices mechanisms, or unwritten) of your third party-pay- issues, then one may consider the use including hinges and other modifica- er, ultimately will determine whether of these physical therapy CPT codes tions for signs of wear and tear along there is reimbursement for these addi- to be perfectly appropriate when pro- with information on maintenance tional physical therapy codes. viding foot orthotics. If your opinion requirements. Some issues to consider: Does is that the fitting and adjustment of a As with foot orthotics, the AFO/ the fitting and adjustment include foot orthotic includes the training on LLP specifically includes the time the Instructions for Use (both oral the use of the device, then perhaps spent fitting and adjusting the de- and written) that you provide your your opinion is that the use of these vice, unless with the rare exception patient with every dispensed DME PT codes is inappropriate. in which the patient presents to you devices? Is training the patient really Third-party payers who have with an AFO/ LLP ordered by and a separate entity to the initial fitting reimbursement policies for custom billed by another provider. and adjustment? How much train- fabricated foot orthotics may pro- If you consider the training on ing is really required for a patient to vide a solution to this coding dilem- the use of the AFO/LLP separate learn how to use foot orthotics? ma if the policy clearly states that from the fitting and adjustment on The primary instructions and is- fitting, adjustment, and training on the use of AFO/LLP, then the time sues addressed in training patients on the use of the appliance are included Continued on page 42

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PT Codes (from page 40) geons, physical medicine, etc. As ducing. The use of these codes in with all the timed services you bill, the podiatric practice may be worth- spent training the patient and what be especially careful about separat- while exploring, but they are not you did to train them must clearly be ing out the time spent on training without significant documentation differentiated from the time spent fit- and differentiate that time from the issues and audit potential. ting and adjustment of the AFO/LLP dispensing and fitting aspect. Be Thanks to my two esteemed col- device. specific in your documentation on leagues Drs. David Freedman and Additionally, any time taken to what constitutes training for CPT Alan Bass for inspiring this month’s fit, adjust, and train the patient on codes 97760-97763. Some addition- column and providing some insights the device may not be counted in the al considerations: 97760-97763 are on its content. PM calculation of an appropriate E/M listed within the Physical Therapy services. Your perspective on wheth- Section of CPT; they will count to- Dr. Kesselman is er the four issues above are separate wards the patients’ annual financial in private practice in from the fitting and adjustment of the limit on PT. If the PC codes are also NY. He is certified AFO will dictate whether these are amended with the KX modifier, the by the ABPS and is a separate actions and must be reflec- financial limits can be overridden. founder of the Acad- tive in your documentations. However, physical therapy codes emy of Physicians in CPT codes 97760-97763 all have amended with a KX modifier have Wound Healing. He is per 15-minute qualifiers. Thus, it is a high recoupment rate on post-pay- also a member of the possible to bill for more than one ment audit or denial on pre-payment Medicare Provider Communications unit of a specific training CPT code. audit. One additional large caveat to Advisory Committee for several Regional To summarize, CPT codes consider—the use of specific modi- DME MACs (DMERCs). He is a noted expert 97760-97763 are not only underuti- fier requirements (GP) requires the on durable medical equipment (DME) for the 42 lized by podiatrists but by other documentation of a “Plan of Care”, podiatric profession, and an expert panelist for health physical therapists, occupa- which may be more than most phy- Codingline.com. He is a medical advisor and tional therapists, orthopedic sur- sicians are worth committing to pro- consultant to many medical manufacturers.

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