Orthotic Management Codes with Fitting and Adjustment HCPCS code

Question:

We recently hired a physical therapist to allow patients to receive therapy in our office if they wish. We have never coded for therapy services prior to his arriving and are unsure if his recommended CPT codes are correct.  

The therapy service will be provided on the same day as the physician’s E&M service.  

The physician wrote an order for physical therapy and a knee orthotic with locking knee joints, prefabricated, and will bill HCPCS Code L1831 with an E&M code in addition to physical therapy.  

The therapist suggested CPT codes are: 

97162 (Initial physical therapy evaluation, moderate complexity) 

97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minute) 

We are not questioning the accuracy of CPT code 97162 but seeking guidance on CPT code 97760. 

Answer:

Thank you for your inquiry to KZA. You are correct to question the accuracy of reporting the orthotic management codes with this specific DME L code. 

HCPCS code L1831 is defined as “Knee orthosis (KO), locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment” The inclusion of “fitting and adjustment” in the code descriptor precludes reporting 97760 as this would define overlap between the valuation of the L code and CPT code 97760; both include fitting in their definitions.  

Remember to append modifier 25 on the therapist evaluation CPT code to show the significant separate service rules were met (differentiation between physician E&M service and therapist evaluation code).  

*This response is based on the best information available as of 4/25/24.