SCOPING REVIEW OF CODING, BILLING, AND REIMBURSEMENT TO INFORM POTENTIAL CONSIDERATION OF FEE FOR SERVICE IN ORTHOTICS AND PROSTHETICS

Fee for service (FFS), or volume-driven care, is giving way to fee for value, or value-driven care, in healthcare professions who use current procedural terminology (CPT) codes to describe professional services for reimbursement. The Orthotic and Prosthetic (O&P) profession oppositely utilizes the healthcare common procedure coding system (HCPCS) to describe the provided device and included service as codes. These HCPCS, or fee for device (FFD) codes, are largely product rather than service based, focusing on product features and function more than professional clinical service. The project aim was to scope the literature to determine if sufficient evidence is available to outline the developmental process, rationale, and key milestones along the course of coding system development for those professions that utilize CPT service codes in the FFS model. A second aim was to provide an overview of historic reimbursement models and contemplate potential alternative O&P reimbursement models. This serves to facilitate next steps and assists in developing recommendations for the O&P profession to consider potential transition from an FFD to FFS or other model of reimbursement. The scoping review yielded non-experimental narrative articles. Thus, utilizing traditional literature appraisal is unlikely to assist in informing next steps to determine how to convert the O&P profession’s payment structure. However, many valuable concepts can be taken from the history of coding and billing paradigm development and change in other professions and should be considered. The second part of the project outlined concepts and models that may be valuable in contemplating the transition from FFD.