09/08/2021

Billing for Second Pair of Orthotics-NYSHIP

I participate with NYShip (Empire Plan ). My patient wants a second pair of custom orthotics and told me they will be covered. (He already got the first pair of orthotics April 2021 from me). How do I go about getting the second pair? Do I need a special code to send with the electronic superbill? Thank you very much

The Empire Plan could cover a second pair of orthotics provided there is supporting documentation to justify medical necessity if the patient is receiving a second pair within one year of the last. When billing the claim for a second pair of orthotics, it should be billed the same way as the initial claim and no special coding is required. When the EOB is received from the Empire Plan, they will most likely deny or pend the claim requesting the supporting documentation. Once all the supporting documentation (office notes, letter of medical necessity, etc.), the claim should be paid at the same rate as the first pair of orthotics. I would recommend that a call be made for prior authorization prior to dispensing.