Health Information Management

Q/A: CPT code 97760 and L-codes

APCs Weekly Monitor, June 12, 2009

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Q:  Please clarify the overlap between CPT code 97760 and the L-code. Precisely, when and where does it occur? I know that billing a visit charge in addition to the L-code is inappropriate, but please explain when overlap of the L-code with CPT code 97760  would necessitate the use of modifier –52.
 
A: Modifier –52 would not be warranted, according to AMA’s CPT® Assistant, February 2007 and December 2005. CPT code 97760 is time-based and reported at 15 minute intervals. If the splint has a Level II HCPCS code (usually an L-code), this code is reported for the orthotic and for the evaluation and fitting of the orthotic.CPT code 97760 is appropriate for reporting  any training time  necessary for the patient to use the orthotic. The documentation must  support reporting  both codes, including specific information  to support reporting training with CPT code 97760. 
 
The orthotic and prosthetic management codes are time-based and intended for reporting  once for each 15-minute increment. Materials and supplies may be reported separately with an appropriate supply or material code (e.g., CPT code 99070 or HCPCS Level II code). HCPCS L-codes for orthotics include the evaluation and fitting components of the service. However, any training time associated with using the orthotic may be reported using CPT code 97760. The time reported must be only for time that the patient is present.
 
CPT code 97760 includes additional orthotic management and training during follow-up visits, including:
  • Exercises performed in the orthotic
  • Instruction pertaining to skin care and orthotic wearing time
  • Time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity

If a HCPCS II code (e.g., an L-code) is reported for an orthotic, the provider may use only  CPT code 97760 code to describe the services associated with training, as described in the preceding clinical scenario. Assessment and fitting of the orthotic are included in the  L-code. The health care practitioner's documentation should reflect the services provided and support reporting either the CPT code or the HCPCS II code. CPT code 97760 remains a 15-minute timed code



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