CATEGORY
Orthotic and Prosthetic Training and Management
CODE TYPE
Timed based code
Billed in 15 minutes increment
ADD-ON CODE
No add-on code
ORTHOTIC TRAINING
This service provides training on using an orthotic device on the upper extremity, lower extremity, and/or trunk. The provider may assess and adjust the fit for the device. He develops a treatment plan that takes into account the patient’s needs and their ability to function.
Orthotics:
- Orthotics are used to increase functional efficiency of function.
- Used as adjunct along other physical therapy techniques like muscle strengthening, gait training, etc.
Assessment Includes:
- Physical capabilities
- Level of amputation
- Psychological status
- Patient’s expectation
- Complete Gait analysis
CPT 97760 and 97761 are used for initial orthotic and prostheses assessment and training.
CODING GUIDELINES
» Require the professional skills of qualified healthcare professionals that includes:
- Physical Therapist
- Occupational Therapist
- Chiropractors
- Physical Therapist Assistant
- Occupational Therapy Assistant
» Billed in 15 minutes increment
» Requires a therapy modifier (GP, GN, GO, CO, CQ)
» CMS 8-minute rule and AMA rule of Eights are applied
CMS 8-Minute Rule:
A minimum of 8 minutes of direct contact with the patient must be provided for a single unit of 97760 to be billed:
| Units | Number of Minutes |
|---|---|
| 1 unit | ≥ 08 minutes through 22 minutes |
| 2 units | ≥ 23 minutes through 37 minutes |
| 3 units | ≥ 38 minutes through 52 minutes |
| 4 units | ≥ 53 minutes through 67 minutes |
| 5 units | ≥ 68 minutes through 82 minutes |
| 6 units | ≥ 83 minutes through 97 minutes |
| 7 units | ≥ 98 minutes through 112 minutes |
| 8 units | ≥ 113 minutes through 127 minutes |
The pattern remains the same for treatment times of more than 2 hours.
AMA Rule of Eights:
“AMA guidelines state that incremental intervals of treatment performed on the same session may be added together when determining total time in direct contact of a qualified healthcare provider with the patient is necessary. Each unique timed service is counted separately instead of combining the time from multiple units”
PHYSICAL THERAPY MODIFIERS
Below mentioned modifiers are used when services are provided for the respective plan of care:
| MODIFIERS | PLAN OF CARE |
|---|---|
| GP | Outpatient Physical Therapy |
| GO | Outpatient Occupational Therapy |
| GN | Outpatient Speech-Language Pathology |
| CQ | Outpatient Physical Therapy by a Physical Therapist Assistant (completely or partially) |
| CO | Outpatient Occupational Therapy by an Occupational Therapy Assistant (completely or partially) |
TOTAL NO. OF BILLABLE UNITS
06 units are allowed per date of service by CMS but more units can be billed if justified by medical notes
MEDICAL NECESSITY
99760 is considered medically reasonable and necessary if:
- Indication for proper use and application of orthotics is present.
- Functional use of the orthotics is documented.
- Distinct treatment procedures for both upper and lower extremity(ies).
REIMBURSEMENT GUIDELINES
For reimbursement following elements must be documented the Physical Therapy Notes:
- Total direct time spent by the provider with the patient as well as total duration of treatment.
- Documentation of results of assessment and patient’s functional level.
- CPT 97760 does not include cost of material or casting time. It is suggested to confirm specific insurance coding and billing criteria for casting supplies.
- Payment made not be made in following conditions:
- If physical therapy services are provided to a patient in a hospital
outpatient department - If physical therapy services are provided to an inpatient by an independently
practicing healthcare provider.
Note:
As per CMS guidelines, CPT code 97760 should not be reported with CPT code 97116 (Gait training) for the same extremity.
