Prosthetists and orthotists obtain advanced degrees, complete residencies, and pass board certification exams. They dedicate at least four years of post-graduate education to becoming clinically proficient in O&P for the safety and well-being of end users. Paradoxically, O&P clinicians, being relegated as suppliers of durable medical equipment, are only paid for delivering medical devices to patients, not for their clinical care.
It would be similar to an optometrist only being able to bill for contact lenses and not the exam. Or an OT only being able to bill for custom hand splints and not the evaluation and follow-up, or a PT only being able to bill for custom knee braces and not the rehab sessions. Wait, those last two hit a little too close to home: custom splints and braces? Aren’t those under the O&P practitioner’s scope of practice? Isn’t that just the situation that we are in? Physicians, OTs, and PTs could deliver a custom orthosis or prosthesis and bill for their clinical time and expertise along with the medical device, but instead they usually refer patients to a prosthetist/orthotist who has the necessary clinical expertise and specialized skill set.
So why are those who haven’t gone through as much O&P training as we have allowed to bill for their expertise and clinical care via CPT codes and medical devices via HCPCS codes, while those who are specifically trained in this domain aren’t?
I did some digging through the Code of Federal Regulations (CFR) to find my answer. In doing so, I discovered that there are established O&P-specific CPT evaluation and management (E/M) codes. In my understanding, which I’m more than happy to be corrected on, the American Medical Association (AMA) is the governing body that created and maintains the CPT E/M code set.
According to the physical and occupational therapy associations (APTA and AOTA), it is within the scope of practice for PTs and OTs to bill for their clinical time via CPT codes to evaluate, treat, and train individuals with custom or off-the-shelf O&P devices and also to bill via HCPCS codes for them. Historically, when the O&P profession has tried to restrict access to the HCPCS billing codes from anyone other than those certified by ABC or BOC, APTA and AOTA opposed it.
The AMA defines OTs and PTs as “non-physician qualified healthcare professionals.” This determination seems to be made at the AMA’s discretion. According to the Social Security Act, “non-physician qualified healthcare professionals” can bill for their clinical healthcare services. I haven’t found the CFR’s definitive list of who this subset of healthcare professionals is, but I have found that the secretary of labor or someone they designate can define them.
Ultimately, it would seem that the AMA, and not congress or legislation, is the gatekeeper to O&P professionals’ ability to bill for our clinical time and expertise. I found this all to be very interesting and had not truly understood it before.
Instead of trying to pass legislation that restricts access, maybe we could get PT and OT support by lobbying their organizations for expanded access to the codes that already exist?
Perhaps I’m just sharing something that everyone else already understood, but I would love to hear your thoughts and suggestions.
Chris Baschuk, MPO, CPO, FAAOP(D), is the director of clinical services, Point Designs. To read a longer version of this article, visit his LinkedIn page at linkedin.com/pulse/who-really-cares-healthcare-chris-baschuk.
