Ultimate Guide to CPT Code 97760

How often have you come across CPT code descriptions that have left you in utter confusion? Selecting the most appropriate CPT code from a vast code set is challenging, especially when minor and often unnoticeable differences make them distinct from one another. The situation with Orthotic Management and Training and Prosthetic Training codes 97760, 97761, and 97763 is quite similar. 

To make the distinction clear, we will dissect CPT code 97760 in this ultimate guide and tell you how codes 97760 and 97763 compare and contrast. Moreover, we will look at the real-world applications of the 97760 CPT code and its billing best practices to enhance your coding accuracy. So, read on to know the details. 

97760 CPT Code – Description

The Current Procedural Terminology (CPT) code 97760 is an orthotic and prosthetic management code. It is commonly reported by occupational therapists to seek reimbursement for an initial 15-minute training session on the correct use of an orthotic device attached to the body’s upper or lower extremity or trunk area. 

The provider fits the device on the patient and adjusts it if needed to enhance its functionality. Moreover, the timed encounter involves developing a treatment plan, training the patient on how to wear the device, skin checks, and assessing the patient’s comfort level. 

Medicare Part B covers the CPT code 97760, given that the assessment, fitting, and training of the orthotic device was medically necessary. Moreover, the provider should be registered with Medicare, and the service must be performed in an outpatient setting. The Medicare reimbursement rate for the 97760 CPT code in the current fiscal year is between $43 and $69, depending on the MAC locality and outpatient facility.   

Scenarios Where CPT Code 97760 is Applicable

Let’s look at some real-world scenarios where CPT code 97760 can be used most appropriately for efficient billing and seamless payment collection. 

Fitting of Transtibial Prosthesis for Lower Extremity Amputation

Transtibial or below-the-knee prosthetics are specialized devices that offer support and functionality to patients who have lost their leg from the knee joint to the foot. Several types and designs are available for this prosthetic, and each one is custom-made to ensure an intimate fit. 

Scenario

A transtibial amputee visits the physical therapist’s office after being prescribed a below-the-knee prosthetic. The therapist directly meets the patient, assesses the fabricated device, fits it on the patient, and asks the patient about his comfort level. If the device requires modification, the therapist will make a note of it. The patient is asked to stand and walk in it for training purposes, after which the therapist will create a management plan and instruct the patient on its correct use. For example, how long should the device be worn, how should it be taken care of, and what to do in case of pain or skin infections? 

Take Away  

Report CPT code 97760 if the face-to-face session lasted 15 minutes in an outpatient setting and was the first of its kind for the patient.  

Training & Management of Spinal Orthotics for Back Pain  

In this case, the focus area is the body’s trunk. Spinal orthotics, like back supports and braces, treat back pain, fractures, and poor posture by correcting the curvature of the spine and realigning the vertebrae. A therapist at an outpatient facility will report CPT code 97760 when he assesses, fits, and reviews the spinal orthotic on a patient suffering from back pain, trauma, or deformity. 

Scenario

An elderly patient with a hunched back meets a physical therapist for the fitting and management of a lower back brace to alleviate pain and control curving. The therapist meets the patient in an assisted living facility for 15 minutes to try on the brace, adjust its fit (if needed), and guide the patient on the orthotic’s daily use. 

Take Away

Report the 97760 CPT code for every 1 unit of initial direct contact with the patient for the training and management of a spinal orthotic in an outpatient setting. Maintain adequate documentation to prove its medical necessity, e.g., severe lower back pain. 

CPT Code 97760 vs. 97763 – Key Differences

CPT codes 97760, 97761, and 97763 are all part of the ‘Orthotic Management and Training and Prosthetic Training’ code range as maintained by the American Medical Association. However, each of these denotes a specific service delivered by the occupational therapist. For example, while CPT codes 99760 and 99763 cover the training and management of either a prosthetic or orthotic device, CPT code 99761 reports the assessment, fitting, and training of only a prosthetic device. 

You must also note that in 2018, CPT code 97762 was deleted and replaced with code 99763 to offer a better degree of specificity. Below, we have compared CPT codes 99760 and 99763 to highlight their similarities and differences. 

	CPT Code 97760	CPT Code 97763
Medical Specialty	Occupational Therapy, Physical Therapy, Chiropractic	Occupational Therapy, Physical Therapy, Chiropractic
Time Duration	15 minutes	15 minutes
Parties Involved	Provider and patient	Provider and patient
Purpose of the Service	Assessment, training, and management of orthotic/prosthetic device	Training and management of orthotic/prosthetic device
Degree of Encounter	Initial	Subsequent
Medicare Reimbursement Rate	$42.99 – $68.22	$46.80 – $75.80

From the table above, we can see that the primary differences between CPT codes 97760 and 97763 are the order of the encounter, what is involved in each visit, and the Medicare reimbursement rates. 

CPT code 97760 is an initial encounter involving the first assessment and fitting of the orthotic or prosthetic device. During this visit, the patient receives initial training on how to wear and use the device. Hence, the Medicare reimbursement rate for the 97760 CPT code is typically lower. 

In contrast, CPT code 99763 reports follow-up visits to learn the appropriate use of the device, especially due to skin irritation, trips and falls, and pain. Therefore, Medicare pays a slightly higher rate for this subsequent visit.  

97760 CPT Code – Reimbursement Guidelines

Failure to follow standardized guidelines and payer-specific coding policies can result in claim denials and loss of revenue. You need a steady flow of reimbursements to keep your practice sustainable amidst the growing competition in the healthcare landscape. So, how can you prevent errors and oversights when coding and billing CPT code 97760 to ensure accurate and timely payment collection? 

The answer is down below. We have compiled some CMS-approved tips that will help you code and bill 97760 better, paving the way for maximized reimbursements. Take a look! 

Conduct a Comprehensive Initial Assessment 

The term ‘assessment’ in the description for CPT code 97760 extends to patient assessment as well. As a provider, you must assess the patient’s condition before fitting an orthotic or prosthetic device. For example, you must consider the patient’s functional limitations, complications, impairments, and comfort level with the device before instructing him to wear one. You must also record the findings and submit them later as supporting documentation. 

To assess the device, you are required to report its HCPCS ‘L’ code and check whether the device is the right size, fit, make, and model. If the device was modified (custom-built for the patient), you must make a note of it in your physical therapy notes and use the correct ‘L’ code to denote the time it took to cast the orthotic/prosthetic. 

Document and Provide Proof of Medical Necessity 

The next step is to ensure that you maintain and submit complete and correct documentation to prove the medical necessity of a training and management session on an orthotic or prosthetic device denoted by CPT code 97760. 

For example, you must include the patient’s complete medical history, X-ray reports, clinical notes highlighting amputated limbs, damaged muscles, etc., and why a skilled therapist’s assistance was needed to fit the device and train the patient, e.g., the patient was elderly or using the equipment for the first time, etc. Please note that any orthotic/prosthetic or service that is not medically necessary, such as the custom-fitted burn or pressure garments, will not be reimbursed as the patient can easily do without it. 

Note the Time for Provider-Patient Encounter

The 97760 CPT code is time-based. It reports the first 15 minutes of a provider-patient encounter during which the orthotic or prosthetic is assessed and fitted on the patient. You must be mindful of the time you spend in direct contact with the patient to report 1 unit of training component (15 minutes) for CPT code 97760.  

Plus, you must take down the total duration of the session to accurately bill for other occupational therapy services like CPT code 97165 for OT evaluation. It will help you collect rightful reimbursements for the time you spend with the patient, whether evaluating the patient’s condition for 30 minutes or offering training for another 20 minutes.  

Record the Device’s Functionality, Treatment Plan, and Results

Your detailed documentation must include the device’s functionality and performance metrics. For example, you must take the measurements of the orthotics or prosthetics and record how functional it was at the time of the fitting, e.g., its elasticity and grip. 

Next, you must document the treatment plan you had created for the patient, e.g., how many times a day they should wear it or how long they should walk in it. The last thing you must record for the accurate reporting of CPT code 97760 is the initial results of using the prosthetic/orthotic device. These will become visible as the patient tries on the device and trains in it for the first 15 minutes. 

Ensure the Service was Offered in an Outpatient Setting

CPT code 97760 indicates an outpatient physical or occupational therapy service. Hence, the code cannot be used if the training and management were performed in an inpatient setting. You can report the 97760 CPT code if a qualified and registered healthcare professional provides the orthosis and instructions on using it in the patient’s home, an outpatient center, or a skilled nursing facility (SNF).  

According to the Centers for Medicare and Medicaid Services (CMS), the 97760 CPT code is billable by:

• Outpatient rehabilitation facilities,
• Outpatient hospital therapy departments 
• Comprehensive outpatient rehabilitation facilities (CORFs)
• Nursing homes (patients covered under Medicare Part B stay)
• Home health agencies (patients not under an HH care plan)

Do Not Report CPT Code 97760 with 97116 for the Same Extremity

Medicare does not permit the use of CPT code 97116 with 97760 if you are placing the device on the same extremity (upper or lower). Physical and rehabilitation therapists use code 97116 to denote 15 minutes of gait training, like climbing stairs or walking comfortably without strain. Hence, the two services are separately billable and should not be reported together even if the focus area (upper/lower extremity or trunk) is the same.   

Final Word 

97760 is one of the most used CPT codes in occupational therapy. Physical, occupational, pediatric, and rehabilitation therapists report CPT code 97760 when they provide orthotics or prosthetics management and training in an outpatient setting for the first 15 minutes. This code is applicable when the provider tests the orthotic/prosthetic and fits it on the patient for the first time. The 97760 CPT code also includes device modification, training the patient on it, and offering instructions for its management.  

Claim submission for code 97760 involves comprehensive documentation to prove the medical necessity of the service. If this is something that you are struggling with, our professional physical therapy billing services cover everything, from patient scheduling to medical coding and documentation to clean claim filing. Take the first step toward effortless billing!

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