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Orthotics

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Prior Authorization

Prior Authorization for Orthoses

Please visit the above page for more information on prior authorization for orthoses

For Codes: L1832, L1833, L1851, L0648, and L0650

F2F and WOPD Required Effective: 04/13/22

Prior Authorization Required:

  • 04/13/22: NY, IL, FL, and CA
  • 07/12/22: MD, PA, NJ, MI, OH, KY, TX, NC, GA, MO, AZ, and WA
  • 10/10/22: Nationwide

For these HCPCS codes requiring prior authorization there are special modifier requirements, in certain situations, to bypass the prior authorization process when billing the claim.

Claims will be subject to prepayment review for:

  • Suppliers providing in Acute/Emergent situations utilizing the ST modifier; or
  • Practitioner/physicians who are also suppliers NOT in a competitive bid area utilizing the ST modifier; or
  • Suppliers who are practitioner/physicians or occupational therapist (OT)/physical therapist (PT) in a competitive bid area utilizing the KV or J5 modifier.

Refer to chart below for HCPCS codes and requirements:

Documentation and Modifier Requirements to Bypass Prior Authorization

HCPCS
Code
Brace under
Competitive Bid
Modifier
 

Acute/Emergent Situations with suppliers, or Practitioner/physicians who are also suppliers NOT in a competitive bid area

Modifier

Suppliers who are
a physician/practitioner
or OT/PT
in a competitive bid area
L1832 No ST N/A
L1833 Yes ST KV/J5
L1851 Yes ST KV/J5
L0648 Yes ST KV/J5
L0650 Yes ST KV/J5

 

ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary, suppliers may opt to bypass the prior authorization program. These claims will be billed using modifier ST and will be subject to 100% prepayment review.

  • Suppliers providing in Acute/Emergent situations utilizing the ST modifier will bypass the prior authorization program. These claims will be subject to 100% prepayment review.
  • Practitioner/physicians who are also suppliers NOT in a competitive bid area will also utilize the ST modifier and bypass the prior authorization program. These claims will be subject to 100% prepayment review.

J5 and KV modifier - Physicians/OT/PT who are non-contract suppliers furnishing OTS back and knee braces to their own patients will utilize the KV and J5 modifiers, respectively. In this case, the claim will bypass prior authorization review. 10% of these claims will be subject to prepayment review. (The ST modifier is not to be used by practitioner/physicians or OT/PTs who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.)

Prior Authorization Timelines

Policy Initial Review
Decision Timeframe
Expedited Review
Decision Timeframe
PAR Decision Valid
Orthoses 5 business days 2 business days 60 days

 

Tips

Topic Details

Billing for Orthotics Requiring Prior Authorization in Acute/Emergent Situations and Under Competitive Bidding Program

CMS has given special consideration for acute situations for orthotics. Prior authorization requirements will be suspended for HCPCS codes L0648, L0650, L1832, L1833, and L1851 for the following criteria:

  • Suppliers providing in Acute/Emergent situations where a two-day expedited review would delay care and risk the health or life of the beneficiary can utilize the ST modifier to bypass the prior authorization program. These claims will be subject to 100% prepayment review.
  • Practitioner/physicians who are also suppliers NOT in a competitive bid area providing in Acute/Emergent situations where a two-day expedited review would delay care and risk the health or life of the beneficiary can utilize the ST modifier and bypass the prior authorization program. These claims will be subject to 100% prepayment review.
  • For a physician/practitioner or occupational therapist (OT)/physical therapist (PT) or hospital furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), must bill with modifiers KV, J5 or J4, respectively conveying that the DMEPOS item is needed immediately. When submitted with one of these modifiers, 10% of claims will be subject to prepayment review.

ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary.

J4, J5 and KV modifier – Physicians, occupational, physical therapists, and hospitals who are non-contract suppliers in a competitive bid area who provide OTS back and knee braces to their own patients will utilize the KV, J5, and J4 modifiers, respectively. (The ST modifier is not to be used by Physician/Practitioner or OT/PT who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.)

  • J5 - Physical therapists and occupational therapists
  • KV - Physicians and other treating practitioners
  • J4 - Hospital
Canceled Orders for Customized Items (salvage value)
  • Suppliers may be reimbursed for the labor and parts involved in customization when an order is canceled, or the beneficiary expires prior to delivery. When billing, include a claim narrative explaining reason for cancellation (e.g., death, canceled, etc.) in Item 19 of CMS-1500 claim form or NTE segment of loop 2400 on an electronic claim. Date of service (DOS) on claim must be date order was canceled or date of beneficiary death. Please refer to the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 20.3 for more information.
Competitive Bid
Concentric Adjustable Torsion Joints Find correct coding information for the Concentric Adjustable Torsion Joints
Correct Billing Custom Fitted Orthotics
Correct Coding Custom Fitted
Custom Fabricated
  • A custom fabricated orthosis is one which is individually made for a specific beneficiary (no other beneficiary would be able to use this orthosis) starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc. It requires more than trimming, bending, or making other modifications to a prefabricated item.
  • To support medical necessity of custom fabricated rather than a prefabricated orthosis, include detailed documentation in treating physician's records. This information will be corroborated by functional evaluation in orthotist or prosthetist's records and must be available upon request
  •  
  • Billing Not Otherwise Classified (NOC) custom fabricated - If the item is custom fabricated and does not have a specific HCPCS code, a complete and clear description of the item, including what makes this item unique, and a breakdown of charges (material and labor used in fabrication) should be entered in the narrative field of an electronic claim or on Item 19 of a paper claim.
DMEPOS Payments While Inpatient
Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthotics
  • 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.
Prefabricated Orthotics

Off the Shelf vs Custom Fitted
  • Off-the-Shelf - If an orthosis needs only minimal self-adjustment for fitting at the time of delivery, it is considered off-the-shelf.
  • Custom Fitted - If an orthosis requires more than minimal self-adjustment, it is considered custom fitted. A certified orthotist or an individual who has equivalent specialized training can perform more than minimal modifications for a custom fitted prefabricated orthotic. (e.g., physician, treating practitioner, physical therapist, or occupation therapist in compliance with all applicable federal and state licensure and regulatory requirements). See article Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised
Item Provided Prior to Surgery
  • Items can be provided and billed prior to surgery when item is medically necessary, prior to surgery, coverage criteria is met, and documentation is included in ordering physician’s medical record. If there is no medical necessity until after surgery, item should not be provided until after the surgery has been performed and medical need exists.
Replacement
RT/LT Modifiers
  • Suppliers must bill each item on two separate claim lines using the RT and LT modifiers and 1 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.
Upper Limb Orthoses Coding

 

Resource

 

Last Updated Wed, 22 Jun 2022 14:41:19 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

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