Who really cares in healthcare?

Happy Friday Everyone,

Imagine you are a healthcare provider. Because of your desire to help a specific subset of patients, you have obtained an advanced degree, gone through a residency, and passed board certification exams in your field. You've dedicated at least 4 years of post-graduate education to becoming clinically proficient in your field. Other healthcare providers refer patients to you so that you can meet their very specific needs.

You see a patient in your office for a clinical evaluation. You spend 1-2 hours going through that evaluation and educational process. During that time you collect measurements, range of motion, manual muscle testing, patient reported outcome measures, as well as other applicable outcome measures. Prior to the visit your office administration team has spent time scheduling, confirming the appointment, collecting documentation, running insurance verification etc.

Because of your clinical expertise and knowledge, that same patient decides to entrust their care to you. They inform you that they would like to proceed with the clinical intervention that has been prescribed and you evaluated and confirmed that they are a candidate for. Now say that unfortunately, the patient's insurance denies the authorization of the intervention. You spend more administrative time going through an appeals process to obtain the authorization. This process gets drawn out over several months requiring many hours of time devoted to collecting further documentation, calling the healthcare providers who referred the patient to you and asking them to be more detailed and explicit in their clinical documentation even though it is outside of their clinical expertise and training. Ultimately after all of this, a medical director at the insurance carrier, who also is not trained in your area of expertise, decides that the intervention is "not medically necessary." The reason that they give is because it doesn't involve the dominant side of the patient's body. And that's the end of the road. There is no further recourse or method of appeal.

You and your clinic have invested many hours and multiple visits with the patient. There have been overhead costs, administrative costs, liability insurance coverage costs, and consumable costs. Now imagine that after all of this care that you have provided, you are not able to recover any of that cost in time or effort because you are not allowed to bill for your clinical time and/or expertise.

Instead, you, and everyone else in your profession, are only allowed to be paid if you deliver a medical device to the patient. A medical device, mind you, that requires a significant investment of time, education, and training prior to delivery. Not to mention all of the continuing follow-up, training, and adjustment for several years after it has been delivered in order to monitor, maintain, and confirm that it is providing the function that it is designed to do. It would be similar to a dentist only being able to bill for a crown and not any of the office visits and diagnostics leading up to the procedure or follow-up care afterward. Or an optometrist only being able to bill for glasses and contact lenses and not the evaluation and annual reevaluation. Or an occupational therapist only being able to bill for custom hand splints and not the evaluation and follow-up, or a physical therapist only being able to bill for custom knee braces...

Wait, those last two hit a little too close to home, because those last two things, custom orthoses, are under your scope of practice. Yet that is the situation you find yourself in. You can only bill for those devices and not your care. That's because you, my friend, are a Certified Prosthetist Orthotist. And as such, even with all your schooling and training, you cannot bill for your clinical time and expertise. However, those aforementioned occupational therapists and physical therapists, on the other hand, if they were to deliver a custom orthosis or prosthesis, even with maybe a week at most of formal training on the subject, are able to bill for their clinical time and expertise along with billing for the actual medical device. Physicians can bill for both too even though, often, their level of training on the subject may be limited to a lecture or two during medical school.

"That's because you, my friend, are a Certified Prosthetist Orthotist. And as such, even with all your schooling and training, you cannot bill for your clinical time and expertise."

In full transparency, most physicians don't personally provide custom prostheses and orthoses. That's why they referred them to you as a Certified Prosthetist Orthotist in the first place. I don't know of a single physical or occupational therapist who isn't cross-trained and certified as a prosthetist that provides custom prostheses to patients. There definitely are, however, a fair number of occupational therapists and physical therapists that provide some types of custom or off-the-shelf orthoses. In particular, those that are Certified Hand Therapists provide a decent amount of orthoses.

So why is it that those who haven't gone through as much training are able to bill for their expertise and clinical care via Current Procedural Terminology (CPT) codes along with the medical devices via Healthcare Common Procedure Coding System (HCPCS), in this case prostheses and orthoses, while those who are specifically trained in this domain, aren't?

This past week I was doing some digging through the code of federal regulations which led me down a rabbit hole regarding the classification of prosthetists and orthotists. In doing so I discovered that there are already established CPT evaluation and management (E/M) codes for orthotic and prosthetic management and training. Specifically here are the codes that seem applicable to our profession:

• CPT CODE 97116 Gait training (includes stair climbing)
• CPT CODE 97535 Self-care/home management training (e.g., activities of daily living [ADLs] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact, each 15 minutes
• CPT CODE 97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
• CPT CODE 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
• CPT CODE 97761 Prosthetic training, upper and/or lower extremities, initial prosthetic encounter, each 15 minutes
• CPT CODE 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes
• CPT CODE 97763 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

In my research and understanding, which I'm more than happy to be corrected on, the American Medical Association (AMA) is the governing body that creates and controls the CPT codes. The above codes were created along with the following codes:

• CPT CODE 97161 Physical therapy evaluation: low complexity
• CPT CODE 97162 Physical therapy evaluation: moderate complexity
• CPT CODE 97163 Physical therapy evaluation: high complexity
• CPT CODE 97164 Physical therapy re-evaluation
• CPT CODE 97165 Occupational therapy evaluation, low complexity
• CPT CODE 97166 Occupational therapy evaluation, moderate complexity
• CPT CODE 97167 Occupational therapy evaluation, high complexity
• CPT CODE 97168 Occupational therapy re-evaluation

The AMA created this specific subset of codes so that physical therapists, occupational therapists, and with another specific subset of codes, outpatient speech language pathologists, could bill for their clinical time. Using the above codes and the scope of practice claimed by both the American Physical Therapy Association (APTA) and THE AMERICAN OCCUPATIONAL THERAPY ASSOCIATION, INC (AOTA), physical therapists and occupational therapists are therefore allowed to bill for their clinical time to evaluate, treat, and train individuals with custom orthoses and custom prostheses via the above CPT codes as well as bill with HCPCS codes for the custom orthoses and prostheses that they deliver.

The AMA has very specific guidelines on how they go about updating the CPT codes. That information can be found here:

https://www.ama-assn.org/about/cpt-editorial-panel/cpt-code-process

The purpose and mission of the CPT code system can be found here:

https://www.ama-assn.org/about/cpt-editorial-panel/cpt-purpose-mission

From that last page.

"The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the Department of Health and Human Services to name national standards for electronic transaction of health care information. This includes transactions and code sets, national provider identifier, national employer identifier, security and privacy. The Final Rule for transactions and code sets was issued on Aug. 17, 2000. The rule names CPT (including codes and modifiers) and HCPCS as the procedure code set for:

• Physician services
• Physical and occupational therapy services
• Radiological procedures
• Clinical laboratory tests
• Other medical diagnostic procedures
• Hearing and vision services
• Transportation services including ambulance"

My reading and understanding of the above, again open for correction, is that the AMA controls the CPT code set and establishes what providers are allowed to bill for specific subsets of the CPT codes. Because the CPT coding system has been codified as "the code set", it is ultimately the AMA who controls whether or not prosthetists and orthotists can have access to bill the above listed CPT codes for their evaluation and management of individuals needing custom orthoses and prostheses. On the other hand CMS controls the HCPCS code taskforce that manages the changes and updates to that code set.

The AMA restricts access for OTs, PTs, and SLPs by defining them as "non-physician qualified healthcare professional." This determination seems to be made at their discretion. In the Social Security Act there is reference to "non-physician qualified healthcare professional" as those being able to bill for their healthcare services. Yet, I am still trying to locate within the CFR the specific definition of a "non-physician qualified healthcare professional" where it identifies which subset of healthcare professionals these are. Who is "qualified"? What I have found is that in 29 CFR § 825.125 it designates that the secretary of labor or someone that they designate has the ability to define who "non-physician qualified healthcare professionals" are.

All that being said, it would seem that ultimately it is the AMA, and not congress or legislation, that is responsible and the gatekeeper to prosthetists and orthotists being able to bill for our clinical time and expertise. I found this all to be very interesting and had not truly understood it before.

"...the codes needed for prosthetists and orthotists to be able to bill for our clinical time already exist..."

Another helpful link:

https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral

Historically, when prosthetists and orthotists have tried to restrict access to the HCPCS billing codes from anyone other than those certified by The American Board for Certification in Orthotics, Prosthetics & Pedorthics, Inc. (ABC) or The Board of Certification/Accreditation (BOC) as was the case with legislation in 2017, it has been opposed by the American Physical Therapy Association (APTA) and American Occupational Therapy Association (AOTA).

https://www.apta.org/news/2017/10/03/cms-shelves-controversial-orthotics-and-prosthetics-proposal

It seems that the codes needed for prosthetists and orthotists to be able to bill for our clinical time already exist, it's just a matter of obtaining recognition to bill them from the AMA. Instead of trying to pass legislation that restricts access, maybe we could get the support of the APTA and AOTA by lobbying for expanded access to the codes that already exist?

Maybe I'm just sharing something that everyone else already understood, but I would love to get everyone's feedback. Thoughts?

Sincerely,

Chris Baschuk, MPO, CPO, FAAOP(D)

#prosthetics #orthotics #reimbursement #healthcare #insurance #billing