Billing CPT 97760 with covered diagnosis

ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT

Orthotic Training (CPT code 97760)

The draft LCD states that “usually less than 30 minutes is necessary for static orthotics training” and that typically “orthotic training can be completed in three (3) visits.” That may not be true for patients with complicated orthoses, or those whose activities require increasing use of the affected limb. AOTA requests that the time frequency limitations be removed as prohibited by “rule of thumb” restrictions. Documentation always should support the number of visits requested.

COVERAGE LIMITATIONS
AOTA takes exception to the definitive statement, “Medicare will cover no more than two re-evaluations per patient per course of injury/illness”. We understand that re-evaluation of a person occurs as part of every treatment session, and it would not be appropriate to bill 97004 each time. However, we do not agree that it is appropriate to initiate a seemingly incontrovertible coverage rule in an LCD. As stated above, we do not support “rule of thumb” frequency and duration numbers, but completely support the need for documentation when unusual circumstances arise.

ICD 9 CM Code List
The draft LCD states that "it is the provider's responsibility to select the codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted." AOTA agrees with this statement and believes that Highmark should rely on the provider to choose the appropriate codes. For this reason, we believe that the code lists that follow the statement above should be deleted. Further, we are concerned that the list of ICD-9-CM codes in the draft LCD is missing codes that could be used to support medical necessity. For example, the code 438.9 Unspecified late effects of cerebrovascular disease is not listed in the draft LCD, yet is specifically included in CMS Transmittal 14144 among the ICD 9 codes "that are likely to quality for the automatic process therapy cap exception based on clinical condition or complexity."

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