A Look at Medicare Guidelines for Orthotics Billing

Orthotics billing has always been a tough domain in the healthcare area. And this is primarily because one is dealing with revenue cycle management, specifically with Medicare guidelines. A recent update by Noridian Medicare,^[1]  brings into sharp focus these very complexities while discussing custom-fitted orthotics billing when no custom fitting is completed and no OTS equivalent is available. This complex situation further reiterates the need for precision and expertise in orthotics billing so as to avoid claim denials and stay compliant.

What do you need to know about the Noridian Medicare Update for your orthotics billing: Key Points to Consider:

The update emphasizes that claims for custom-fitted orthotics in the absence of custom fitting and an OTS equivalent will be denied. Medicare strictly defines custom-fitted orthotics as those requiring substantial modification or fitting to the individual beneficiary. Without this customization or fitting, suppliers cannot bill these items under custom-fitted HCPCS codes.

Key Takeaways from the Update:

• Compliance is always Crucial: Billing custom-fitted orthotics requires documentation of the customization or fitting process. Any deviation can result in denied claims.
• Proper HCPCS Coding: Suppliers must use appropriate codes for OTS orthotics if no custom fitting is performed.
• Documentation Requirements: Comprehensive records of patient assessments, modifications, and fitting processes are mandatory to support claims.

This level of scrutiny from Medicare showcases the complexity of orthotics billing and the potential financial risks for healthcare providers.

How Sun Knowledge Services Inc. Fits In

For the last 15 + years, Sun Knowledge Services Inc. has been a trusted name in RCM for durable medical equipment Prosthetics, Orthotics and Supplies (DMEPOS) providers, including those offering orthotics and prosthetics. With a deep understanding of Medicare guidelines and payer-specific requirements, Sun Knowledge ensures accurate billing and seamless claim processing.

Here’s how Sun Knowledge Can Help:

• Expertise in Orthotics Billing – Sun Knowledge’s dedicated team of billing professionals is well-versed in Medicare policies, including updates like the recent Noridian guidelines. This expertise ensures compliance and reduces the risk of denials.
• Accurate HCPCS Coding – The importance of proper coding cannot be overstated in orthotics billing. Sun Knowledge ensures that every claim is accurately coded, whether for custom-fitted orthotics or OTS items, minimizing delays and rejections.
• Full Documentation Support – The team also helps providers maintain comprehensive documentation-patient assessments, customization process, and fitting records-as required by Medicare’s strict rules.
• End-to-End Revenue Cycle Management – The fact that Sun Knowledge provides end-to-end support, right from eligibility verification to submission of claims, denial management and even daunting A/R follow-up and more; adds to the advantages. This holistic approach ensures that providers focus on patient care while the expert can solely focus on handling the revenue cycles.
• Proven Results in Denial Management – Orthotics billing often faces high denial rates due to documentation or coding errors. Sun Knowledge’s proactive denial management strategies help recover lost revenue and improve cash flow.

Partnering with Sun Knowledge: The Competitive Edge

With the blend of technology, expertise, and commitment to excellence, Sun Knowledge offers a value proposition that is unbeatable for any orthotics provider. offering pace with continuous regulatory updates, like those from Noridian Medicare, various CMS rules, codes etc, the expert work on ensuring that providers are always compliant and financially secure.

Our Achievements in DME and Orthotics Billing Include:

• 99% accuracy in claims submission
• 30% reduction in operational costs for our clients
• Industry leading turnaround times for claim resolution

For orthotics providers grappling with the intricacies of Medicare guidelines, Sun Knowledge serves as a trusted partner, simplifying billing processes and ensuring maximum reimbursement.

The recent Noridian Medicare update on orthotics billing highlights the need for precision and expertise in navigating Medicare’s guidelines. Sun Knowledge Services Inc. provides the perfect solution, offering end-to-end RCM support tailored to the unique challenges in orthotics billing services. By partnering with Sun Knowledge, orthotics providers can streamline their operations, ensure compliance, and optimize revenue.

Let Sun Knowledge take the complexity out of orthotics billing so you can focus on delivering quality care to your patients.

[1] https://med.noridianmedicare.com/web/jddme/article-detail/-/view/2230715/update-for-billing-custom-fitted-orthotics-when-no-custom-fitting-is-completed-with-no-off-the-shelf-equivalent-available