Article Detail - JA DME

Due to recent inquiries from suppliers, it has come to our attention that some miscellaneous codes used for billing off-the-shelf orthotics, when a custom fit orthotic is provided but no custom fitting is performed, may require specific policy and laterality modifiers. These claims must also include a narrative with the information outlined below.

If you have received denials for these claims, please correct and resubmit them or pursue redeterminations through the appeals process. We encourage you to use the Noridian Medicare Portal for Redeterminations/Appeals submissions.

For detailed billing instructions, refer to the Noridian Medicare website under "Correct Billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off the Shelf Equivalent." The guidelines are as follows:

• Miscellaneous Codes: When no corresponding prefabricated off-the-shelf HCPCS code is available, use one of the following codes:
  • L1499 - Spinal orthosis, not otherwise specified
    • Apply any policy-specific modifiers as required
  • L2999 - Lower extremity orthosis, not otherwise specified
    • Apply any policy-specific modifiers as required
    • Use RT or LT modifiers as appropriate
    • For bilateral items on the same date of service, list each item on a separate claim line with the RT and LT modifiers and 1 unit of service (UOS) on each line (e.g., L2999 RTKX)
  • L3999 - Upper limb orthosis, not otherwise specified
    • Apply RT or LT modifiers as appropriate
    • For bilateral items on the same date of service, list each item on a separate claim line with the RT and LT modifiers and 1 unit of service (UOS) on each line (e.g., L3999 RT)
• Narrative Requirement: Include a narrative on the claim with the following information:
  • HCPCS code of the item being provided
  • Indication of "OTS" (off-the-shelf)
  • Supplier's Retail Price (SRP)

Example: L1820 OTS $150 SRP