Provider Reimbursement

PaperworkAt present, TheraTogs products have not been code-verified by the CMS Pricing, Data Analysis and Coding (PDAC) authority. As you probably know, we are working on solutions to this limitation that will provide you with superior clinical options and PDAC-verified HCPCS II codes.

However, reports from the field tell us that numerous state Medicaid programs and a number of private payors will reimburse for TheraTogs systems under one of these codes:

Applicable TheraTogs Systems:

Wunzi, PTA, Lower Extremity, Full Body

HCPCS Descriptor:

Spinal orthosis, not otherwise specified.

Comments:

Orthotic appliances and devices are appliances and devices used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.

Applicable TheraTogs Systems:

Wunzi, PTA, Lower Extremity, Full Body

HCPCS Descriptor:

Lower extremity orthoses, not otherwise specified

Comments:

A spinal orthosis is an orthotic device (commonly referred to simply as an orthotic or an orthosis) and an external apparatus that is applied to the body to limit the motion of, correct deformity in, reduce axial loading on, or improve the function of a particular spinal segment of the body.

Applicable TheraTogs Systems:

WunziFull Body

HCPCS Descriptor:

Upper limb orthosis, not otherwise specified

Comments:

Applicable TheraTogs Systems:

Wunzi, PTA, Lower Extremity, Full Body System

HCPCS Descriptor:

Miscellaneous DME supply, accessory, and/or service component of another HCPCS code

Comments:

Recommended coding per California Medi-CAL: “TheraTogs is a medical device used as a garment and strapping application to provide gentle, prolonged muscle stretch and alignment guidance that replicates the manual positioning of supervised therapy. A professional rehabilitation clinician may offer TheraTogs for clients with typical neuromotor or sensory deficits. and alignment guidance that replicates the manual positioning of supervised therapy. A professional rehabilitation clinician may offer TheraTogs for clients with typical neuromotor or sensory deficits.” (MediCAL Bulletin # 429, June 2011)

Applicable TheraTogs Systems:

Wunzi, PTA, Lower Extremity, Full Body

HCPCS Descriptor:

Durable medical equipment, miscellaneous.

Comments:

HCPCS codes and descriptors are copyrighted by the American Medical Association and are used herein
in accordance with the CMS/AMA agreement and the Fair Use doctrine of US copyright law.

Claim Filing Suggestions

Medicaid programs provide funding for DME and orthopedic devices that are to be used by trained individuals as part of a detailed plan of care for therapy services. Medicaid programs do not, generally, provide funding for therapy modalities and tools. Although TheraTogs systems can be used in clinic to support therapy sessions, they are designed and customized for individual use at home to provide carryover and to ensure compliance with therapeutic objectives. Therefore, TheraTogs should not be defined in claim filings as a therapy modality or tool, because that is an inaccurate description.

Our experience is that Medicaid coverage for TheraTogs under miscellaneous codes (requiring a manual claim filed “by report”) relies on the interpretation of need by the claim reviewer. Medicaid reviewers will sometimes define TheraTogs as a spinal orthoses, and sometimes as a medical device – the standard practice differs by state. Every claim must include a firm and persuasive LMN written by the most appropriate clinician.

  • When your state Medicaid program defines the TheraTogs system as a spinal orthoses, use code L1499. This code can be appropriate for the Wunzi, PTA, or Full Body Systems.
  • When your state Medicaid program defines the TheraTogs system as a medical device or DME, use code E1399 or A9900, as directed by the program. This code can be appropriate for the Wunzi, PTA, Lower Extremity or Full Body Systems.

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