Orthotics - JA DME

Suppliers may be reimbursed for the labor and parts involved in customization when an order is canceled, or the beneficiary expires prior to delivery. Follow the guidelines for Canceled Orders for Customized Items to facilitate the reimbursement process. Please refer to the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 20.3 for more information.

View Coding Verification Review for a list of HCPCS codes able to be billed that have received a written coding verification review (CVR) by the Pricing, Data Analysis, and Coding (PDAC) contractor.

Find correct coding information for the Concentric Adjustable Torsion Joints.

Refer to the Medicare DMEPOS Payments While Inpatient MLN Fact Sheet for information on inpatient payments, deliveries before inpatient discharge, and interruptions in period of continuous use.

• Medical need prior to surgery - Items can be provided and billed prior to surgery when item is medically necessary and the brace is required to be worn prior to surgery, coverage criteria is met, and documentation to substantiate the need is included in ordering physician's medical record.
• Medical need after surgery - If there is no medical need to wear the brace until after surgery, item should not be provided until after the surgery has been performed and medical need exists.

• Off-the-Shelf - Minimal self-adjustment refers to adjustments that can be made by the beneficiary, their caregiver, or the supplier, such as assembling, trimming, or adjusting straps. Minimal self-adjustment does not require any expertise in trimming, molding, assembling, or customizing to fit to the individual; therefore, the adjustment does not need to be performed by a certified orthotist or an individual with specialized training.
• Custom Fitted - More than minimal self-adjustment is when an item must be trimmed, bent, molded, or otherwise modified for an individualized fit. These kinds of alterations require the expertise of a certified orthotist or someone with specialized training in the provisions of orthoses to fit the item to the beneficiary.

View the Repairs page for requirements on orders, narratives on claims, and orthosis labor and minor parts HCPCS codes.

• Allowed due to loss, theft, or irreparable damage or when reasonable useful lifetime (RUL) of original orthosis is met. RUL for DMEPOS items is five years unless LCD/PA specify otherwise.
• See Medical Director written Billing Instructions - LSO and TLSO
• See Medical Director written Orthoses: Replacement of Components Clarification - Republished

Suppliers must bill each item on two separate claim lines using the RT and LT modifiers and one unit of service (UOS) on each claim line. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single claim line, will be rejected as incorrect coding.

Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. View Therapeutic Shoes vs Orthopedic Footwear for more information.

Correct coding is an essential element for correct claim payment. The DME MACs and Pricing, Data Analysis and Coding (PDAC) contractor maintain a variety of resources to assist suppliers in determining the appropriate code for billing upper extremity braces. Please refer to the joint article, Correct Coding of Finger, Hand, Hand-Finger and Wrist-Hand- Finger Braces (Orthoses) - Revised and Correct Coding of Elbow, Shoulder, Shoulder-Elbow-Wrist-Hand and Shoulder- Elbow-Wrist-Hand-Finger Braces (Orthoses revised) for additional information.