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Orthotics

Coverage

Documentation

Reviews/Audits

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

Competitive Bid 2021

Competitive Bid 2021 includes off the shelf back and knee braces

  • OTS back braces HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651
  • OTS knee braces HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852

Prior Authorization

Prior Authorization for Orthoses

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

Requirements for Codes: L1832, L1833, L1851, L0648, and L0650

Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)

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
  • Practitioners/physicians who are also suppliers NOT in a competitive bid area, so not subject to competitive bid rules requiring provision of the item on the same day as professional office visit, and who are providing a brace in an acute/emergent situation utilizing the ST modifier; or
  • Competitive bid suppliers who are also practitioners/physicians or occupational therapist (OT)/physical therapist (PT) IN a competitive bid area and subject to providing item on same day as professional office visit 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. Documentation will be requested to substantiate the acute/emergent situation.
  • Practitioners/physicians who are also suppliers and NOT in a competitive bid area who are providing a brace in an acute/emergent situation are required to use the ST modifier to bypass the prior authorization program. These claims will be subject to 100% prepayment review. Documentation will be requested to substantiate the acute/emergent situation.

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
AFO/KAFO Orthosis

ICD-10-CM Codes that Support Medical Necessity
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.
Coding Verification Review

The only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL)

Knee Orthoses

  • L1845 - Effective for claims with dates of service on or after July 01, 2008
  • L1852 - Effective for claims with dates of service on or after January 1, 2017
  • L1832, L1833 and L1851 - Effective for claims with dates of service on or after October 10, 2022

Spinal Orthoses

  • L0450, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0625, L0626, L0627, L0628, L0630, L0631, L0633, L0635, L0637, L0639 - Effective for claims with dates of service on or after July 1, 2010
  • L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651 - Effective for claims with dates of service on or after January 1, 2014
  • There are two categories of custom fabricated spinal orthoses (codes L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, and L0640)
  • Orthoses that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the beneficiary.
    • Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC web site
Competitive Bid
Concentric Adjustable Torsion Joints Find correct coding information for the Concentric Adjustable Torsion Joints
Correct Billing Custom Fitted Orthotics Without Corresponding OTS Code
Correct Coding Custom Fitted Without Corresponding OTS Code - DMD article
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
Knee Orthosis

ICD-10-CM Codes that Support Medical Necessity
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 - DMD Article
  • 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
  • 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.
  • 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.
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 Tue, 25 Oct 2022 16:39:02 +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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