Coding FAQ - Orthotics

Q: I recently billed Blue Cross Blue Shield for a pair of orthotics for a patient, using the "L3020 coding" and it was returned, as an invalid code. What am I doing wrong?
A: You are billing the correct code for the orthotics themselves. Some companies will demand particular codes so that’s why it’s very important to verify carefully. Did your staff verify that they were covered? That is sometimes the problem.

Q: My billing person told me I can no longer use L3030 for billing my orthotics and a separate fitting code 97504. She said it was an all inclusive code for L0628 for "lumbar sacro-orthosis" flexible, which includes adjustment and fitting. Is this correct? Do you have any change information?
A: The orthotics code is one that is right for billing, along with L3020, but the fitting code changed in 2006 to 97760. I’m not sure where she got the L0628 code, as this is the equivalent of a lumbar belt, so please don't use this!!!

Q: I have been ordering orthotics from Footlevelers since 1986. I do have some billing info that Footlevelers faxed over. I guess there is no way to differentiate between more expensive orthotics like the shoe or boot orthotic with inserts as opposed to just the inserts. We only have the basic L3230 code. The only problem I have run into is when we put the claim in through a private insurance companies like Blue Cross or United Health and the reimbursement rate is so low ($130) that my cost is not even covered! Since I am under contract with the insurance companies, I can't even bill the patient for the balance...  Could I charge another fee when they come in to pick up the orthotics to recoup some of this loss?  I'd appreciate any ideas you have!
A: The problem/question you have here is one that many of your colleagues are suffering with. The problem is not the private health insurers not paying enough in general...it's because you've signed a contract with them to accept their fees. If you were not a participating provider with them, there would be no reason you couldn't accept whatever they paid, then allow the patient to pay the balance. Unfortunately, when you agree to the terms of a provider agreement, you've signed away any rights you have with respect to your fees. At Foot Levelers, we're trying to compile lists of those companies that allow VERY little in the way of reimbursement, and we're hoping to lobby them to at least change the policy to read that they will allow a certain amount, then allow the doctor to balance bill the patient when they agree up front to the cost of the orthotic. That is a slow process.
Also, you mention that they allow $130, and my first concern is to ask if that is per code? As you know, you must bill 2 units of L3020 in order to get the orthotics paid. Are they allowing $130 for only one of the codes? If so, that could be remedied by you billing correctly with two units, thus having a total reimbursement of $260 which is much closer to reasonable.
As for the Shoe- and Sandalthotics, there is technically NO code to cover the shoe and orthotic inside. I've made the suggestion to some others that you bill a more general code or random code like 99070 for a "shoe" and it will usually come back as non-covered. ON most plans, patients can be held liable for the non-covered services unless your agreement forbids you from billing them. Check that out and it could be an easy fix for the more expensive shoes. There again, you may find that most patients are willing to pay cash for the needed stabilizers, thus allowing you to bypass the insurance altogether. Just confirm that this is possible in your provider agreement.
Check the "How To Get Paid for Orthotics" guide for all the ancillary services you can and should be billing in addition to the stabilizers.