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Q&A: Coding and billing prosthetics and orthotics in physical therapy departments

Q. Transmittal 1702 of the Medicare Claims Processing Manual states:

When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patient's use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services. Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services. For example, if the hospital outpatient staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code to describe the fitting and adjustment.

In a physical therapy department, would it be appropriate to also bill CPT code 97760 (Orthotic[s] management and training, each 15 minutes) in addition to, for example, L3763 (Elbow wrist hand orthosis, rigid, without joints, includes fitting and adjustment)? Or would CPT code 97760 be included in the billing of L3763?

A. The HCPCS Level II L code includes the actual supply or device and the fitting and adjustment. CPT Code 97760 includes the time and skill for the clinician to fit and also to train the patient in the use of an orthotic device for one or more body parts. This includes an assessment of the type of orthotic, when appropriate, and of the effectiveness of the device for the therapeutic intent once the clinician fits it.

There is overlap with regard to the two codes. Therefore, we recommend that when billing for both services with both codes, you should use CPT code 97760 with modifier -52 (reduced services) to indicate that the L code that includes the device covers the fitting and adjustment, and that the service paid under 97760-52 is for the training and assessment services.