04/16/2025    Kristin Happel

Orthotics Denial (Michael Orosz, DPM)

A couple of things jump out at me here: 1. Was an
orthotic benefit verification made by your staff
before the patient was casted? 2. Why was a GA
modifier appended to both lines of the L3000?
These two questions are intertwined, as it were.

If an orthotic benefit verification was done,
staff would know if orthotics were covered. If
they were covered, there should be no reason for
the -GA modifiers on the claim. (Check with your
billing company on why this modifier was added)
What the- GA modifier is telling insurance is that
you expect the orthotics to be denied for not
being reasonable and necessary, for Medicare. Was
this a Medicare claim?

In terms of documentation, Optum is very
particular when reviewing claims. What they expect
for documentation should be how every orthotic
casting/fabrication is documented, just so you are
always ready. Our office has dealt with them for
UHC orthotic claims, and they are the only ones
who ask for documentation, so we have it down to a
science.

1. The casting should be documented in total
detail. If it is a foam box casting, you need to
state if it is MASS posture, what you captured in
the casting, etc. 2. The orthotics being
fabricated need to be described in complete
detail, such as UCB Berkeley shell, functional
orthotic, etc, all modifications, postings, top
cover, etc.

Spare nothing in your description of the orthotic
you have ordered. We always send the actual
orthotic order we give to our orthotic lab, as
well as the treatment note when the patient is
casted. When the claim is sent in for the
casting/orthotics, you can either attach your
notes directly to the claim, or wait to get the
request from the insurance company that they want
them. Your call.

But all told, regardless of what you do, some
insurances will take 9 months to finish their
review, some will take 6 months, some will take
more than that or less. This is the business of
being in business (contracted) with some
insurances.

Kristin Happel, Podiatry Biller, Chicago, IL

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