Some things in life are very straightforward. For instance, if you need a new pair of jeans, you simply head to the store (or use my preferred method: ordering online from the comfort of your own home), give your money to the cashier, and walk out the door with exactly what you need. Unfortunately, purchasing things such as splints, prosthetics, and durable medical equipment (DME) isn’t so cut and dried. In fact, when it comes to orthotics and prosthetics billing, there’s a lot of room for error. So, to make sure your patients get with they need—and you get paid what you deserve—stick to the following guidelines:

The PT’s Guide to Billing - Regular BannerThe PT’s Guide to Billing - Small Banner

Obtaining a Provider Number

If you want to receive reimbursement from a Durable Medical Equipment Regional Carrier (DMERC), then you have to provide your number—your DMEPOS number, that is. Not to be confused with your NPI number, your DMEPOS number is required to receive reimbursement for items like splints, orthotics, and other supplies. Medicare considers physical therapists “suppliers,” but DMERCs won’t see you that way until you obtain this number. To do so, you’ll need to fill out and submit a CMS-855S form (along with all of your supporting documents) to Palmetto GBA, the national supplier clearinghouse for Medicare. If you have questions, you can contact the clearinghouse at 866-238-9652 or visit the Palmetto GBA website.

Here are a few additional details:

  • Generally speaking, the application process should take about 60 days.
  • You can also expect a visit from a Medicare inspector before you receive your supplier number.
  • After three years, you will need to re-enroll, which means filling out another CMS-855S form and getting another visit from a Medicare inspector before receiving your number.

Picking the Right Codes

There are several different codes providers can use to bill for orthotics, prosthetics, and DMEs—and it’s absolutely crucial that you pick the right one. Here are some tips for making sure you’ve chosen the right code for the service you provided—and for the payer you’re billing (Note: All CPT codes—including the following codes—are property of the AMA):

97760: Orthotics Initial Encounter Code

Description:  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 minutes.

Not only does this code cover orthotics management and training, but it also includes the patient assessment and fitting (if you haven’t reported it otherwise). Specifically, this code refers to the initial encounter. This is a change for 2018, as therapists could previously use this code for subsequent visits. You should report this code for services performed on any and all regions of the body. 

That said, if you use an L-code, make sure you don’t report 97760. That’s because L-codes cover management and training in addition to building the device. (If you’re out of the loop on L-codes, fear not. We’ll cover those below.)

97761: Prosthetic Initial Encounter Code

Description:  Prosthetic(s) training, upper and or lower extremity(ies), initial prosthetic(s) encounter, each 15-minutes.

Providers should use this CPT code for any prosthetics-related instructions or interventions, including:

  • ADLs for UE and LE amputees,
  • Walking for LE amputees,
  • Donning and doffing activities,
  • Residual limb management, and
  • prosthesis-related self care.

Much like its numeric neighbor 97760, this code applies only to the initial encounter.

97763: Orthotic and Prosthetic Management

Description:  Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes.

As we mentioned previously, you should only use 97760 and 97761 for initial encounters. Otherwise, you would use 97763, which includes the same activities described by the other two codes, but is reserved specifically for subsequent encounters.

You may be wondering about 97762—particularly if you’ve used this code in the past—but as of January 1, 2018, 97762 was deleted and replaced with 97763.

L-Codes: Splinting and Bracing

So, what are L-codes? These are the HCPCS codes providers must use when billing for splints, braces, and any other services related to assessment, fabrication, and supplies—including follow-up. As mentioned above, providers should not bill 97760 or 97761 with any L-codes on private payer or workers’ comp claims, as those codes cover the assessment.

Before you can bill L-codes to Medicare, you must be a certified DME provider. If you haven’t received your DME certification yet, here are some tips for billing Medicare for orthotic services:

  • Bill 97760 for the initial assessment;
  • Bill the patient for the device or supplies; and
  • Bill 97763 for subsequent visits.


Now, on to the good stuff: getting paid. There’s a lot at play here, so let’s dissect what, exactly, payers are reimbursing you for during these interventions. (Note: The information below refers to how Medicare reimburses for prosthetics and orthotics and does not necessarily reflect how commercial payers reimburse for these interventions. That said, many [if not most] commercial insurance payers align themselves with Medicare policies, so this should serve as a good general guide.)

For prosthetics, Medicare reimbursement includes:

  • evaluation,
  • fitting,
  • parts and labor,
  • repairs due to normal wear or tear within the first 90 days of the delivery date, and
  • adjustments made during fitting and within the first 90 days of the delivery date (not including adjustments brought on by changes in the remaining limb or a patient's level of function).

For orthotics, Medicare reimbursement includes:  

  • evaluation,
  • measurement and/or fitting,
  • fabrication and customization,
  • materials,
  • cost of labor, and
  • delivery.

Renting or Selling DME

If your patient decides to rent or purchase a DME item, your DMERC will want to know. You can inform your DMERC of the patient’s decision by including one of the following modifiers on the claim:

  • BR: The beneficiary has elected to rent the item.
  • BP: The beneficiary has elected to buy the item; or  
  • BU: You have informed the beneficiary of his or her purchase or rental options, but he or she has not made a decision after 30 days.

Proving Medical Necessity

For certain items, the DMERC requires a certificate of medical necessity (CMN). Each DMERC has its own list of items requiring a CMN, but these lists typically include the following items:

  • osteogenesis stimulators,
  • TENS units,
  • wheelchairs (motorized and manual),
  • CPAP machines,
  • lymphedema pumps,
  • hospital beds,
  • support surfaces,
  • seat lift mechanisms, and
  • power-operated vehicles.

For instructions on how to complete a CMN, visit this page on the Noridian website.

Billing for TENS Units

Billing for TENS units is little tricker than billing for other pieces of DME. In fact, it can even be difficult to receive reimbursement for TENS units, with nearly half of all claims for TENS units being denied. The number-one reason for those denials? Incorrect billing procedure. The second most prevalent reason for denials? The claim failed to prove medical necessity.

To start, you must obtain a written order prior to delivery (WOPD) before you can even hand over the unit and provide the DMERC with a CMN (as referenced in the previous section). Furthermore, as far as Medicare is concerned, there are only two reasons why a patient would need to purchase a TENS unit: acute post-op pain and chronic pain. So, make sure your CMN justifies one of these conditions in order to receive payment.

Now for the really fun stuff. As long as the provider is DME certified, the provider will bill the patient for a “rental” payment of 10% of the purchase price—less coinsurance and/or any deductible is allowed—for the first two months of use. This is essentially a trial period, which gives the attending physician a chance to determine whether the patient needs to actually purchase the unit. If the physician deems it medically appropriate, then the full amount for the unit will be due (the carrier will not adjust this amount for the two monthly payments). You can then bill your DMERC for the two-month rental period as well as the actual purchase.

For TENS, the HCPCS codes are E0720 and E0730. For TENS supplies, the codes are A4557, A4595, and E0731.

When buying a new pair of jeans, there isn’t much to it outside of picking the right fit. But when it comes to orthotics and prosthetics, the fit is only half the battle. Got any tips of your own? Leave them in the comment section below.

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • The PT’s Guide to Surviving a Medicare Audit Image

    articleMay 30, 2016 | 5 min. read

    The PT’s Guide to Surviving a Medicare Audit

    “How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes …

  • Video Tutorial: Selecting the Correct Complexity Level for PT and OT Evals Image

    articleOct 13, 2016 | 1 min. read

    Video Tutorial: Selecting the Correct Complexity Level for PT and OT Evals

    The holidays will be here before we know it—and that means PTs and OTs will be required to use the new evaluation and re-evaluation CPT codes before we know it, too. And these codes bring with them the gift of complexity. But, unlike that snowman sweater from Great Aunt Sheila, therapists can't exchange these codes; so, whether they want to or not, PTs and OTs have to learn the ins and outs of coding for evaluative complexity …

  • Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update Image

    articleOct 5, 2017 | 5 min. read

    Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update

    Hey, have you heard the good news? CMS has completed all required action items laid out in the Jimmo v. Sebelius settlement. If you’re scratching your head and wondering why that matters, here’s the rundown: a few years ago, a group of Medicare providers alleged that CMS contractors made determinations on claims for skilled care based on an inappropriate “Improvement Standard.” These providers took CMS to court, and the court determined that CMS needed to clarify and …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • Double Duty: How to Bill for PT and OT on the Same Day Image

    articleNov 12, 2018 | 6 min. read

    Double Duty: How to Bill for PT and OT on the Same Day

    In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties. This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day? While the …

  • Brace Yourself: Decreased Payments Might be Coming Image

    articleApr 14, 2015 | 3 min. read

    Brace Yourself: Decreased Payments Might be Coming

    As we warned at the end of last month , the times they are a-changin’. You’re likely well aware of the legislation that could do away with the Sustainable Growth Rate (SGR)—and extend the therapy cap for another two years. We had hoped to have better news for you at this point, but we’re still hanging tight while the Senate sings their own off-key version of Wilson Phillips’ “Hold On.” It’s April 14, 2015. That means the …

  • Founder Letter: My Evaluation of the New PT and OT Eval Codes Image

    articleNov 3, 2016 | 5 min. read

    Founder Letter: My Evaluation of the New PT and OT Eval Codes

    Over the last several years, healthcare providers in general—and rehab therapists, specifically—have been hit with a seemingly constant barrage of regulatory requirements. And the vast majority of these initiatives—PQRS, functional limitation reporting, MPPR, ICD-10, and the like—have either: Had a direct negative impact on our payments, or Forced us to devote extra time to satisfying the criteria of the requirements—with zero compensation for that time. So, it should come as no surprise that the rehab therapy community …

  • Why Physical Therapists Should Support the CONNECT for Health Act 2017 Image

    articleAug 14, 2017 | 6 min. read

    Why Physical Therapists Should Support the CONNECT for Health Act 2017

    The US Senate recently introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act 2017 (S.1016) . If passed, the CONNECT for Health Act would remove several barriers to utilizing telehealth with Medicare patients—which would present a valuable opportunity to the physical therapy profession. Here’s why PTs should strongly consider supporting it: It will allow PTs to deliver, and receive reimbursement for, physical therapy telehealth services. As it stands, Medicare only provides …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.