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.

Time

Question:

Our physician is coding by time; he thinks this is the best for him.  Frequently with a new patient he will also do an injection.  He documents his total time for the day but does not document the amount of time performing a minor procedure (billable).  There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?  

Answer:

CPT states “Time” may be selected based on the total amount of time spent on the date of encounter, excluding time spent for services that are defined by a separately reportable CPT code.  This means that the total time must exclude the amount of time spent related to the minor procedure.  If not documented, KZA recommends asking the physician to amend the note if possible (attesting that the time is accurate to the best of their knowledge) or reporting the service based on MDM.  

*This response is based on the best information available as of 4/11/24.

Date of Service

Question:

We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday.  Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday.   Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?  

Answer:

The correct date of service is the actual date of service when the attending physician saw the patient.  In this case, it will be Wednesday even if the attending physician links the note to the resident note from the previous date.  

*This response is based on the best information available as of 3/28/24.

Diagnosis Coding Excludes 1 Codes

Question:

Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR.   We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship.  Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.     

Answer:

No, we should never change anything in the provider documentation or remove information from the provider’s assessment and plan.  Great news to hear you are reviewing your claims edit reports timely and it appears your edit is set up correctly in your system.  The “Excludes 1” is an ICD-10 coding guideline or a coding rule found in the Conventions for the ICD-10-CM.  A type 1 Excludes note is a pure excludes note.  It means “NOT CODED HERE”. An Excludes 1 indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note.  An Excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.  For the complete information and definition of Excludes Notes please refer to Section 1A Conventions for the ICD-10-CM #12. 

*This response is based on the best information available as of 3/14/24.

DME Billing Inquiry

Question:

With Medicare, some of our patients come in on a different day other than the office visit to pick up their DME.  Do we use the date they pick up the DME item or the date of the office visit for billing?  

Answer:

The date of service for billing in this instance would be the date the DME is picked up (date of delivery to the patient).  

*This response is based on the best information available as of 2/29/24.

DME Billing Inquiry

Question:

Do you have any tips on how to handle Medicare Replacement/Part C/Advantage patients for possible non-coverage?

Answer:

Medicare Advantage Plans are required to cover what Medicare covers at a minimum. You should reach out to the individual plan and inform them of this. You can also attach the Medicare coverage policy when you appeal the claim.

*This response is based on the best information available as of 2/15/24.