Are Economics Influencing Your Clinical Recommendations?

Exactly when did we allow a patient's insurance plan or dispensable income dictate our clinical recommendations? Was it around 2008, when the economic purse strings started to tighten, or even earlier? If you used to recommend custom orthotics as a regular part of your practice, but slowed down or stopped altogether, you are not alone. Maybe your patients lost their insurance or maybe you were tired of feeling like a "used car salesman" – trying to convince them to invest in their feet when the pain was in their back.

After a while, it becomes a grind; as a result, many chiropractors have let this aspect of their practice slip away and are only gradually reconsidering the value of helping their patients heal from the ground up. However, if the bottom line for not offering custom orthotics is economic in nature, there is a way to get a win-win for both you and your patient, whether you take insurance or run a cash practice.

Consider this scenario: Your patient has been seeing you for a number of years and presents with plantar fasciitis. You try many techniques and modalities to control the inflammation, but the underlying cause is that they are overweight; therefore, the plantar fasciitis never resolves.

Being the good doctor you are, you coach your patient on good nutritional habits, stretching and regular activity; but this is where you hit a crossroad. They can't exercise with pain in their foot; in fact, they have also started having pain in their knee. What is your next clinical decision – would a custom orthotic help?

Most chiropractors would agree that a custom orthotic would help this patient, yet find themselves not making the recommendation for one of the reasons mentioned above:

• You don't offer orthotics anymore.
• You don't think your patient can afford them.
• You don't know the codes to get successful reimbursement.

Let's start with the first reason first. If you don't offer orthotics anymore, it's time to get back in the habit. The population is getting older and obesity continues to be a problem. Even if you have a wellness or family practice, you can't avoid these demographics and the foot problems that come with them. Don't deny your patients the chance to get better.

In addition, as an expert in the closed kinetic chain, you understand that the gait of your patient directly impacts the function of their spine. If you feel like you need a refresher, look into a webinar that will refresh your knowledge on assessment and casting, as well as the technology now available.

If affordability or the perception of affordability is the only obstruction to your patient's relief from pain, you have two options available. You can allow them to pay for the custom orthotic over three to four payments (I recommend no more than four payments), doing this through postdated checks or a credit card on file. You can also have them do a trial with a quality, pre-fabricated orthotic and see if it gives them relief. This trial-and-error approach is a great way for your patient to educate themselves about the value of a custom orthotic and that the investment is worth every penny.

The final reason many chiropractors have stopped offering custom orthotics is the administrative tasks and knowledge required to successfully collect insurance. Solo practitioners are even less inclined than chiropractors who practice in multidisciplinary clinics with designated insurance administrators.

Successful insurance billing is a process that begins with your examination, diagnosis and the creation of a treatment plan. Once you have established the medical necessity for a customized orthotic, the next step is to determine the correct diagnostic code. A common error is to diagnose the spinal condition and not link it to an extremity condition. Without justifying how the extremity and spinal conditions are interdependent, it is unlikely you will receive reimbursement.

Once your coding is established, you need to verify whether the patient's insurance will cover custom orthotics, how much they will cover, whether there is a co-payment, the allowable limit, prescription requirements, and coverage for orthotics checkout (follow-up). The verification process should consist of a routine and thorough set of questions that clearly establishes exactly what needs to be submitted for reimbursement.

The final step is the billing process, which includes the CPT / HCPCS, modifier, diagnostic code, charges and units. The most common code is L3020, but this must be linked to the correct diagnosis code to be successfully reimbursed. You may also look into outsourcing billing so you can focus on treating patients and helping them feel their best.

An example of the billing process is to link code L3020 to an ICD code (for example, 724.2 lumbalgia) and a CPT code (for example, 98943, extraspinal chiropractic manipulative treatment, and 97760, orthotic management and training for foot and ankle). You would then use the diagnosis reference number to link the diagnosis to the treatment.

One of the caveats to watch out for is noncompliance in fee schedules for insured versus non-insured patients. For example, if you charge an insured patient $250/foot for L3020, but $150/foot for a non-insured patient, this is not considered compliant by the Office of Inspector General of the Department of Health and Human Services. One way to gain compliance is to join a cash discount network.

Custom orthotics are the missing link for many spinal conditions and help millions of Americans get back on their sore, aching feet and contribute to their community. I urge you to not be discouraged by tough economic times or difficult insurance codes. Help your patients be the best they can be from the ground up.