Article Detail - JA DME
Billing for Custom Fitted Orthotics When No Custom Fitting Is Completed With No Off-The-Shelf Equivalent
When reviewing claims for these items, it has been identified that some suppliers have been billing with the supplier’s cost of the item instead of the supplier’s retail price. Please ensure that the information below for the narrative is included on the claim line.
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
- L3999 - Upper limb orthosis, not otherwise specified
A narrative must be included on the claim line with the following information. Add the 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+
