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29000 Series Strapping/Taping:Strapping/taping may be clinically indicated in order torestore optimal joint dynamics and help improve the overallalignment of the body. Many doctors will use strapping/tapingto estimate the degree of relief the patient will experiencewith custom-made stabilization products.Ankle and/or Foot – 29540Knee – 29530Hip – 29520Low Back – 29220L3020 Foot insert, removable, molded to patient model,longitudinal/metatarsal support, each:This is the most appropriate supply code to describeFoot Levelers’ Stabilizers. However, some carriers mayrequire the use of other codes. It is vital that questionsregarding the use of these codes are asked during theverification process.L3030 is a second possible code related to reimbursementof Stabilizers. The code is very similar to L3020 and is thepreferred code in some policies/states for Stabilizers. Thesimilarity of the codes and the differences between differentpolicies/states mandate that the verification processdescribed in this text be followed carefully. Verificationof both codes is vital.97760 Orthotic(s) management and training (includingassessment and fitting when not otherwise reported),upper extremity(s), lower extremity(s) and/or trunk, each15 minutes. This code can be billed the day the Stabilizersare dispensed to the patient, and may only be used for“custom fabricated” supports. This code includes the fittingof the Stabilizers, training in use, care and wearing time ofthe Stabilizers and brief instructions in exercises while theStabilizers are in place. Direct one-on-one contact by theprovider of service is required and it is a timed code, so besure to properly document the time spent in your daily note.97762 Checkout for orthotic/prosthetic use, establishedpatient, 15 minutes. This code is intended for establishedpatients who have already received the Stabilizers. It isessential for the healthcare practitioner to follow-up witha patient after they have been provided with a pair ofStabilizers. The “checkout” visit would include assessingthe patient’s response to wearing Stabilizers, such aspossible skin irritation or breakdown, determination if thepatient is donning the Stabilizers appropriately, need forpadding, underwrap or socks, and tolerance to any dynamicforces being applied. This code requires direct one-on-onecontact by the provider and is a timed code, so be sure toproperly document the time spent in your daily note.97110 Therapeutic procedure, one or more areas, each15 minutes; therapeutic exercises to develop strength andendurance, range of motion and flexibility. Therapeuticexercise is used to restore strength, range of motion andendurance. Therapeutic exercises may be necessary fora documented loss or restriction of joint motion, strength,functional capacity or mobility, which has resulted froma specific disease or condition. This is also a way to easeadaptation time by breaking up fixations and strengtheningweak muscles in the feet. It’s also possible to use this code forspecific core strengthening exercises, stretching or tubing thatmay be done with rehab equipment such as the Thera-Ciser .Use this code when using a treadmill to acclimate thepatient to walking with the orthotics. Isokinetic footexercises may increase range of motion and reduceadhesions. Lumbar stabilization exercises, when used inconjunction with the Spinal Pelvic Stabilizers, are excellentfor core strengthening. Using a gymnastic ball for stretchingor strengthening exercises can also be coded as therapeuticexercises, with documented medical necessity.98943 Extraspinal Chiropractic Manipulative Treatmentmay be necessary during a course of treatment when anextremity needs to be treated in addition to the spinalregion(s). The five extraspinal regions are the head, includingthe TMJ, but excluding the atlanto-occipital joint, the lowerextremities, upper extremities, anterior ribs, and abdomen.This code is billed only once per encounter, regardless ofthe number of extraspinal regions adjusted.Step 3 – VerificationIt’s crucial to verify insurance coverage to determinewhether Stabilizers are included in the patient’s benefits.Be sure to check with each individual carrier as well asyour state scope of practice that may require a spinalrelated diagnosis, an extremity-related diagnosis or both.It’s recommended that you place a separate call to verifyStabilizer coverage. Do not perform this verification withverification of general insurance benefits.Follow the Foot Levelers Verification Sheet for Orthotics(p. 6) and get all the questions answered.This verification sheet is in addition to your standardverification of coverage.(TIP: Verification can be done before patient comes in.You can copy this sheet and place it on back side of yourexisting verification form)5FLMNL-0217-09 BILLING.indd 54/3/09 11:04:01 AM

Verification Sheet for Orthotics(This assumes that the doctor has done a thorough verification of coverage for general services, and this would be anaddendum to the existing verification form when checking for coverage of Stabilizers.)Patient Name: Insured:Insurance Company: Ins. Co. Phone#Insured’s ID# Insured’s DOB:Policy # Insured’s employer:Patient’s DOB:Circle OneAre custom molded foot inserts (orthotics) covered typically billed as code L3020? YIf yes:Circle One If no:1. Do you have specific written guidelines for the use ofthis code?YNIf so, can you fax/email them to me?Can I find them online?2. Does the fee schedule have a maximum allowable(dollar limit) for L3020?YNYNIs this maximum amount per condition or per year?Is this part of a separate durable medical equipment(DME) benefit?3. Does the fee schedule have a maximum allowable(dollar limit) for L3030?YNYNYN5. Are there certain diagnosis codes necessaryfor reimbursement under the policy?YN2. Do you cover code 98943 when performed by a DC?YYNNYNYNYYNN3. Do you cover Orthotics Management and Training,code 97760?What is the allowable amount?What is the allowable amount?5. Are rehabilitative codes, such as 97110 covered underthe policy?4. What is the co-pay or co-insurance?YNWhat is the allowable amount?6. Do you cover Orthotics Checkout, code 97762?If yes, what are they or where can I find them?Circle One1. Where can I find in writing the orthotics are notcovered in order to explain it to my patient?4. Do you cover therapeutic exercises, code 97110?Is this maximum amount per condition or per year?Is this part of a separate durable medical equipment(DME) benefit?(TIP: Although the Stabilizers themselves maybe specifically not covered, ancillary services areusually covered in most plans.)NYN7. Do you cover extraspinal manipulation, such as code98943?YNYNIf yes, can the RX be from a Doctor of Chiropractic?YYNN8. Do you cover strapping/taping, when billed as code29540?YN8. Do you cover code 98943 when performed by a DC?YN9. Ask the following question if you are in network plan:If orthotics are not covered, can we accept paymentdirectly from the patient?YN6. Is a Letter of Medical Necessity/preauthorization letter needed?Does this need to be submitted prior to or with the claim?7. Is a prescription from a physician required?What is the allowable amount?9. Do you cover Orthotics Management and Training, code97760?Address: What is the allowable amount?10. Do you cover Orthotics Checkout, code 97762?YNYNWhat is the allowable amount?11. Do you cover therapeutic exercises, code 97710?Phone #:Name of rep:Date and time:What is the allowable amount?12. Do you cover strapping/taping, such as code 29540?Name of Carrier for Claims Submission:YNYNIn/out of Network:What is the allowable amount?13. Do you cover extraspinal manipulation, such as code98943?What is the allowable amount?6FLMNL-0217-09 BILLING.indd 64/3/09 11:04:01 AM

Step 4 – BillingThe process of billing for Stabilizers and associated spinaland extremity care is no different than any other clinical billingprocedure. These important concepts must be conveyedin the billing process in order to increase the probability ofreimbursement. Appropriate medical necessity for the servicesrendered must be clearly identified. This section will includeexamples of the completion of the 1500 billing form, diagnosislinking, letters of medical necessity, discussion of non-coveredservices, and an explanation of dealing with uninsured orunderinsured patients in need of Stabilizers for spinal andextremity conditions.(TIP: Make sure that all billing procedures are properlydocumented in your office’s standard operating proceduremanual. Specific billing procedures discussed here can beadded as an addendum to other primary procedures in yourmanual.)InsuranceTo begin the process, there should be established medicalnecessity through history, exam, diagnosis, and treatmentplan. Verification and code selection should have alsooccurred.1500 Form CompletionAs previously discussed, proper diagnostic and proceduralcoding, once selected, must be properly listed on the billingform. When billing the Stabilizers supply code, L3020, youmust bill two line items to indicate both the right and leftStabilizer. While Stabilizers come in pairs, they are codedfor each individual foot. The code represents only ONEStabilizer. The examples below demonstrate appropriatecompletion of the form in boxes 21 and 24 of the 1500billing form. It should be noted that there is more than oneway to complete the form. Both examples are provided here.Option one is to list a line item in box 24 of the 1500 formwith the L3020 in box 24D, the properly linked diagnosiscode in box 24E, the total charge for both Stabilizers in box24F, and a “2” in the units box, 24G.Example of 1500 Form for a Single PairDProcedures, Services or Supplies(Explain Unusual LTEFGDiagnosisCodeChargesDays orUnits4 300.00244 150.00 150.0011If you are billing two pairs in any combination, includingShoethotics and Sandalthotics , the second pair would bebilled exactly the same. Even if you decide to reduce the feefor the second pair, to pass along a multiple pair discount,just reflect the correct dollar amount in box 24F, and followthe instructions above. For a total of four Stabilizers, you willeither have (as in option one) two line items with a “2” ineach units box, 24G. In this example, the total in each lineitem will be 50 percent of the total charge for the Stabilizerpair. Or, as in option two above, you may have four separateline items indicating four Stabilizers, and two would have theRT modifier in box and two would have the LT modifier.Example of 1500 Form for Multiple PairsDProcedures, Services or Supplies(Explain Unusual LTEFGDiagnosisCodeChargesDays orUnits4 600.00444 300.00 300.0022(TIP: It’s also recommended that orthotic services be billedseparately from any other services (ex. an adjustment)provided on the same day. This will avoid interference withreimbursement for other services if the orthotic claim hasto be reviewed.)Option two is to separate the pair of Stabilizers, and listthem on two separate lines. On the first line of box 24, listthe code L3020 with an RT modifier in box 24D, the properlylinked diagnosis code in box 24E, 50 percent of the totalcharge for the pair of Stabilizers in box 24F, and do not usethe units box, 24G. On the next line of box 24, list the codeL3020 with an LT modifier in box 24D, the properly-linkeddiagnosis code in box 24E, 50 percent of the total charge forthe pair of Stabilizers in box 24F, and do not use the unitsbox, 24G.7FLMNL-0217-09 BILLING.indd 74/3/09 11:04:01 AM

Diagnosis LinkingIt’s important to properly link the diagnosis code reported onthe 1500 form in Box 21 to the service code performed in Box24D. This is accomplished by listing the appropriate diagnosisindicator, 1, 2, 3 or 4 or multiple numbers, in 1500 form Box 24E.BOX 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATEITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)1. 724.2 Lumbalgia (low back pain; low back syndrome2. 739.3 Lumbar region3. 719.47 Pain in joint (ankle and foot; arthralgia)4. 728.71 Plantar fascial fibromatosisBOX 24D.CPT/HCPCS1. 98940 CMT — 1-2 spinal regions2. 97760 Orthotic(s) managment and training (includingassessment and fitting when not otherwise reported).This is timed code of 15 minutes each.BOX 24E.DIAGNOSIS REFERENCE NUMBER1, 23, 4BOX 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RELATEITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE)1. 724.23. 719.472. 739.34. 728.71BOX 24D.CPT/HCPCS1. 989402. 97760BOX 24E.DIAGNOSIS REFERENCE NUMBER1. 2.3. 4.BOXES 21, 24D and 24EBox 21 is where you enter your ICD-9 codes. Box 24D iswhere you enter your CPT/HCPCS codes. Box 24E is whereyou enter the diagnosis reference number(s) 1,2,3 or 4 asthey relate to the 4 diagnoses code positions in Box 21. Awritten description of your diagnoses codes in Box 21 isnot necessary. Do not enter ICD-9 codes in Box 24E. Youshould try to fill all 4 positions in Box 21 (only if clinicallyindicated).In the above example Box 24D indicates that a patientreceived a lumbar region chiropractic adjustment (98940)and orthotic management and training for the foot andankle (97760). Box 24E indicates that CPT code 98940links to diagnoses codes 724.2 (lumbar pain) and 739.3(lumbar segmental dysfunction/subluxation) usingdiagnosis reference numbers 1 and 2.Box 24E also indicates that CPT code 97760 links todiagnoses codes 719.47 (ankle and foot pain) and 728.71(plantar fasciitis) using diagnosis reference numbers 3 and 4.(TIP: Listing the diagnosis code associated with thetreatment performed helps to justify the rationale for theservice being provided and should allow the insurancecarrier to process the claim accurately.)Billing Non-Coveredand Under-Covered ServicesSome carriers and contracts limit coverage for Stabilizers toa fee schedule potentially lower than the doctor’s cost.The following are examples of strategies you can use to helpassist the patient in recouping the cost of the Stabilizers.Other Possible Payment Strategies:1. Contracted allowable fee schedule is lower than thedoctor’s cost of the Stabilizer.There is a HCPCS code, S1001 – Deluxe/upgrade itemrequiring patient waiver – which allows a participatingprovider, under certain circumstances, to provide anupgraded product to a patient at the patient’s requestdespite a lower contracted fee schedule. Certain carriersmay allow for billing of this code, thus allowing for thepatient to pay the difference up to the full retail priceof the Stabilizers. Patient acknowledgement must beobtained prior to providing the supply/product. A samplepatient notice/acknowledgement has been provided in thisdocument for you to use. There are two steps for you to doin this situation:a. Find out if their carrier allows for the upgrade/upcharge(see sample provider agreement amendment letteron page 9). Request an amendment to their provideragreement: If the previous strategy is not possible withthis carrier, notify provider relations that you wish toprovide an upgraded supply to your patient that hasa higher cost than the fee allowed under the contract.Let them know that the patient is willing to bear thecost of the difference between the allowable amountand the full price and if the contract may not allow youto do so, you would like to amend it to do that. Show thesample letter to the provider if necessary.b. Get the patient to agree and get patient to signacknowledgement agreement (see sample form fornon-covered products on page 9).8FLMNL-0217-09 BILLING.indd 84/3/09 11:04:01 AM

a. Sample Provider Agreement Amendment LetterDateXYZ Insurance Company123 Anywhere DriveAnytown, NY 12345Re: Request to Amend Provider AgreementDear In-Network Provider Relations Department:As a participating provider in your network plan, I am requesting an amendment be made to my provider agreement.There are certain clinical circumstances where I may need to provide an upgraded clinical product to a patient at thepatient’s request despite a lower contracted rate. The upgraded recommended product that I am referring to is orthotics(Spinal Pelvic Stabilizers). I am requesting that my provider agreement be revised so that I may be allowed to have thepatient pay the cost in excess of the established allowable fee schedule.I will have patients sign a consent form acknowledging that they have been informed that there are other productsavailable at the standard out-of-pocket price that may meet medical necessity. Additionally, when I submit the claim, I willuse HCPCS code S1001. HCPCS code S1001 is used when providing a deluxe/upgrade item requiring patient waiver. Thiscode has been developed for providers to use when billing for high-end equipment or an upgrade. The amount billed willrepresent the cost in excess of the cost of standard equipment. I am also requesting that HCPCS code S1001 be deniedas “patient responsibility” and not a provider write off.Please contact me with your response as soon as possible and let me know if any further information is needed.Sincerely,Dr. Doctorb. Sample Patient Acknowledgement Form for Non-Covered ProductsDear Patient:Your health insurance plan requires you to be responsible for co-payments, co-insurance and deductibles for coveredservices and products as well as those services/products that exceed benefit limits. You are also financially responsiblefor all non-covered services and products.The below listed product is not covered according to your health insurance plan. Your acknowledgement below indicatesthat you have been advised of this information and that you agree to pay this office for the below listed product.Product: OrthoticsDate: 03-15-09Amount: 300.00Patient Acknowledgement:I (patient name), acknowledge that I have been told in advance by this office thatthe product listed above is not covered by my health insurance plan and I agree to pay for this non-covered product at thetime the product is provided. I have also been told that there are other products available at the standard out-of-pocketprice that meets medical necessity.Patient SignatureDate**IMPORTANT: Review your in-network participating provider agreement/contract before implementing this form.9FLMNL-0217-09 BILLING.indd 94/3/09 11:04:01 AM

Other Possible PaymentStrategies (Continued)2. Convenience vs. Not Medically Necessary:When billing insurance, the doctor must keep in mindthat the service he or she is providing meet criteria forreimbursement and these rules hold true for privateinsurance and Medicare. Below, we quote Cigna as anexample.CIGNA HealthCare Definition of Medical Necessity forPhysicians requires that the service billed meet all threeof the fol

PARTIAL LIST OF EXTREMITIES ICD-9 CODES FOR SUPPORTIVE TREATMENT TO THE FOOT OR ANKLE: 714.7 Rheumatoid Arthritis, Ankle/Foot 715.7 Osteoarthritis, Ankle/Foot 718.87 Joint Derangement, Ankle/Foot 726.70 Enthesopathy of Ankle 727.68 Rupture of Tendons, Foot/Ankle 726.73 Calcaneal Spur 727.1 Bunion 728.71 Plantar Fibrometosis