Orthotics - JA DME
Orthotics
Coverage
- Ankle-Foot/Knee-Ankle-Foot Orthosis Local Coverage Determination (LCD)
- Ankle-Foot/Knee-Ankle-Foot Orthosis Policy Article
- Knee Orthoses Local Coverage Determination (LCD)
- Knee Orthoses Policy Article
- Spinal Orthoses: TLSO and LSO Local Coverage Determination (LCD)
- Spinal Orthoses: TLSO and LSO Policy Article
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist Ankle-Foot/Knee-Foot Orthosis [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Knee Orthoses - Custom and Prefabricated [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Spinal Orthoses [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Upper Limb Orthoses [PDF] - Checklist to assist clinicians with documentation requirements
- Clinician Letter - Ankle-Foot/Knee-Ankle-Foot Orthoses [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Documentation of Artificial Limbs and Braces [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Knee Orthoses [PDF] - Letter may be sent to clinicians to help obtain documentation
- AFO/KAFO Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
- Knee Orthosis Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
- Spinal Orthosis Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
- Upper Limb Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Providing Custom Fit as Off-the-Shelf With no Other Alternative - Exception
- Correct Billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off the Shelf Equivalent
- Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding
- Off-The-Shelf or Custom-Fitted Orthotic Lookup Tool
Competitive Bid 2021 Includes Off-the-Shelf Back and Knee Braces
Gap period begins for dates of service (DOS) January 1, 2024 and after.
- OTS back brace HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651
- OTS knee brace HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852
Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
- Required for codes: L1832, L1833, L1851, L0648, L0650, and L3960
- Effective 4/13/22
- Required for codes: L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, L2036
- Effective 4/17/23
Prior Authorization Required for Orthoses
- Required for codes: L1832, L1833, L1851, L0648, and L0650
- Effective nationwide 10/10/22
Prior Authorization Timelines
Policy | Review Decision Timeframe |
Expedited Review Decision Timeframe |
PAR Decision Valid |
---|---|---|---|
Orthoses | 5 business days | 2 business days | 60 days |
Situations to Bypass Prior Authorization (Prior to DOS 01/01/2024)
Process Change
For dates of service beginning January 1, 2024, and after, there is a temporary gap period in the DMEPOS Competitive Bidding Program (CBP) for off-the-shelf back and knee braces. During the gap period, the prior authorization requirements for HCPCS codes L0648, L0650, L1833, and L1851 change and the competitive bid modifiers KV, J4, and J5 are no longer used. Treating practitioners now have the option to follow the prior authorization process with the standard timeframe of review, request an expedited review, or utilize the ST modifier, indicating acute/emergent need. For more information, refer to the Timeline and Updates section of the Prior Authorization and Pre-Claim Review Initiatives webpage on the CMS website. This process change only affects non-contract competitive bid suppliers who are practitioners/physicians, physical therapists, and occupational therapists.
In certain situations, there are special modifiers that will cause the claim to bypass prior authorization when billing a claim. These claims will be subject to prepayment review.
- All Medicare physicians or other treating practitioners IN a Competitive Bid Area (CBA), who are not a CB contracted supplier providing a brace in an acute or emergent situation who are enrolled as Medicare DMEPOS suppliers must append the KV or J5 modifier to the claim
- Practitioners and physicians must append KV modifier to claim line in these circumstances
- Occupational therapists (OT)/physical therapists (PT) must append J5 modifier to claim line in these circumstances
Refer to charts below for modifier requirements when bypassing prior authorization
HCPCS Code Requiring Prior Authorization | Modifier Acute/Emergent Situations All DME Suppliers Example: L1832ST |
---|---|
L1832 | ST |
HCPCS Code Requiring Prior Authorization | Brace Under Competitive Bid | Modifier Acute/Emergent Situations All DME Suppliers Example: L1833ST (Valid DOS 1/1/2024 and after) |
EXCEPTION Modifier Physicians/Practitioners Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception Example: L1833KV (Only valid through DOS 12/31/2023) |
EXCEPTION Modifier OT/PT Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception Example: L1833J5 (Only valid through DOS 12/31/2023) |
---|---|---|---|---|
L1833 | Yes | ST | KV | J5 |
L1851 | Yes | ST | KV | J5 |
L0648 | Yes | ST | KV | J5 |
L0650 | Yes | ST | KV | J5 |
Note: More information about Non-Contract Supplier Exceptions can be found within the Tips section of the Competitive Bidding Webpage.
Tips
Topic | Details |
---|---|
AFO/KAFO Orthosis ICD-10-CM Codes that Support Medical Necessity |
|
Canceled Orders for Customized Items (salvage value) |
|
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
Spinal Orthoses
|
Competitive Bid (Gap period begins 01/01/2024) |
|
Concentric Adjustable Torsion Joints | Find correct coding information for the Concentric Adjustable Torsion Joints |
Correct Coding and Billing Custom Fitted Orthotics Without Corresponding OTS Code |
|
Custom Fabricated |
|
DMEPOS Payments While Inpatient |
|
Knee Orthosis ICD-10-CM Codes that Support Medical Necessity |
|
Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthotics |
|
Prefabricated Orthotics Off-the-Shelf vs Custom Fitted - DMD Article |
|
Item Provided Prior to Surgery |
|
|
|
|
|
RT/LT Modifiers |
|
Medicare Coverage for Shoes - Correct Coding - Revised Therapeutic Shoes vs Orthopedic Footwear |
Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. In order to be eligible for coverage, such items must qualify in either:
|
Therapeutic Shoes vs Orthopedic Footwear - Shoes, inserts, shoe transfer, modifications covered in limited circumstances |
|
Upper Limb Orthoses Coding |
|