Correct Billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off the Shelf Equivalent

When a prefabricated custom fit orthosis is being provided directly to a beneficiary and no custom fitting is completed at the time of delivery, the corresponding prefabricated off-the-shelf HCPCS code must be billed on the claim. When there is not a corresponding prefabricated off-the-shelf HCPCS code for the HCPCS categorized as Custom Fitted Orthotics, one of the following miscellaneous codes must be used for billing.

  • L1499 - Spinal orthosis, not otherwise specified
  • L2999 - Lower extremity orthoses, not otherwise specified
      • Append any policy specific modifiers required per the policy
      • Append RT or LT modifiers as applicable
        • When billing for bilateral items on the same date of service, bill bilateral items on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line
      • Example: L2999 RTKX
  • L3999 - Upper limb orthosis, not otherwise specified
      • Append RT or LT modifiers as applicable
        • When billing for bilateral items on the same date of service, bill bilateral items on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line
      • Example: L3999 RT

A narrative must be included on the claim line with the following information. Add narrative to item 19 of the 1500 claim form or the 2400/NTE segment of an electronic claim.

  • HCPCS code of item being provided
  • OTS to indicate it is off the shelf
  • Supplier’s Retail Price (SRP)

Example: L1820 OTS $150 SRP

Custom fit items require more than minimal self-adjustment at the time of delivery in order to provide an individualized fit. The item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. Adjustments require the expertise of a certified orthotist or an individual with specialized training in the provision of orthotics.

Off-the-shelf items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require the expertise of a certified orthotist or an individual with specialized training in the provision of orthotics.

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