I am delighted that KevinRoot Medical have invited me to provide a twice monthly column on billing and coding issues important to orthotic providers. These columns will provide you with a brief but thorough rationale on orthotic/prosthetic policies and billing practices.
To begin to understand how to bill lower extremity orthotics and prosthetics one needs to have a basic understanding of third-party payment. Since Fee for Service (FFS) Medicare has easy to find resource, let’s start there.
Medicare (FFS) Foot Orthotic policy is contained in the Orthopedic Footwear Local Carrier Decision (LCD) policy. This and other Durable Medical Equipment (DME) LCD may be found on the home page of your DME MAC. Specifics on FFS Medicare coverage will be provided in future Newsletters and Forums
For all other carriers, numerous Federal and State Statutes require transparency, requiring these policies to be provided either to the provider of services (that’s you) or to the patient. Since these policies vary not only by carrier and from policy to policy within an individual carrier, it would be impossible to provide a universal statement applicable to all policies. Becoming familiar with each individual carrier’s website and denoting where their coverage policies are located is of paramount importance in obtaining coverage, prior authorization, and reimbursement information for foot orthotics as well as all other medical, surgical and DME services.
For Medicare you must be enrolled as a DMEPOS provider in order to bill any DME. The rules are far more complex for non-FFS Medicare, state Medicaid and commercial payers. More on all of this in future Forums
