Orthotics - JA DME

• Coverage and Documentation
• Reviews/Audits
• Competitive Bid
• Custom Fabricated
• Custom Fit Orthotics Without Corresponding Off-the-Shelf Code
• Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
• Prior Authorization
• Tips

Coverage and Documentation

• Standard Documentation Requirements for All Claims Submitted to DME MACs
• Clinician Letter - Documentation of Artificial Limbs and Braces [PDF]

Ankle-Foot/Knee-Ankle-Foot Orthoses (AFO/KAFO)

• Local Coverage Determination (LCD)
• Policy Article (includes covered ICD-10 codes)
• Clinician Checklist [PDF]
• Clinician Letter [PDF]
• Documentation Checklist [PDF]

Knee Orthoses

• Local Coverage Determination (LCD)
• Policy Article (includes covered ICD-10 codes)
• Clinician Checklist - Custom and Prefabricated [PDF]
• Clinician Letter [PDF]
• Documentation Checklist [PDF]

Spinal Orthoses

• Local Coverage Determination (LCD)
• Policy Article
• Clinician Checklist [PDF]
• Documentation Checklist [PDF]

Upper Limb

• Clinician Checklist [PDF]
• Documentation Checklist [PDF]

Reviews/Audits

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

Competitive Bid

The following codes were included in competitive bid; however, starting January 1, 2024, there is a temporary gap in the program:

• 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

Custom Fabricated

View Custom Items for information on medical necessity and billing not otherwise classified (NOC) codes.

Custom Fit Orthotics Without Corresponding Off-the-Shelf Code

• 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

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

The following codes require a face-to-face encounter and a written order prior to delivery:

• L1832, L1833, L1851, L0648, L0650, L3960, L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, L2036

Prior Authorization

The following codes require a prior authorization: L1832, L1833, L1851, L0648, and L0650.

Tips

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

View Coding Verification Review for a list of HCPCS codes able to be billed that have received a written coding verification review (CVR) by the Pricing, Data Analysis, and Coding (PDAC) contractor.

Concentric Adjustable Torsion Joints

Find correct coding information for the Concentric Adjustable Torsion Joints.

DMEPOS Payments While Inpatient

Refer to the Medicare DMEPOS Payments While Inpatient MLN Fact Sheet for information on inpatient payments, deliveries before inpatient discharge, and interruptions in period of continuous use.

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.

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.

Repairs

View the Repairs page for requirements on orders, narratives on claims, and orthotic labor and minor parts HCPCS codes.

Replacement

• Allowed due to loss, theft, or irreparable damage or when reasonable useful lifetime (RUL) of original orthosis is met. RUL for DMEPOS items is five years unless LCD/PA specify otherwise.
• See Medical Director written Billing Instructions - LSO and TLSO
• See Medical Director written Orthoses: Replacement of Components Clarification - Republished

RT/LT Modifiers

Suppliers must bill each item on two separate claim lines using the RT and LT modifiers and one unit of service (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.

Therapeutic Shoes vs Orthopedic Footwear

Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. View Therapeutic Shoes vs Orthopedic Footwear for more information.

Upper Limb Orthoses Coding

Correct coding is an essential element for correct claim payment. The DME MACs and Pricing, Data Analysis and Coding (PDAC) contractor maintain a variety of resources to assist suppliers in determining the appropriate code for billing upper extremity braces. Please refer to the joint article, Correct Coding of Finger, Hand, Hand-Finger and Wrist-Hand- Finger Braces (Orthoses) - Revised and Correct Coding of Elbow, Shoulder, Shoulder-Elbow-Wrist-Hand and Shoulder- Elbow-Wrist-Hand-Finger Braces (Orthoses) for additional information.