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Orthotics

Coverage

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

Competitive Bid 2021 Includes Off-the-Shelf Back and Knee Braces

  • 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

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
EXCEPTION
Modifier Physicians/Practitioners
Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception
Example: L1833KV
EXCEPTION
Modifier OT/PT
Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception
Example: L1833J5
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)
  • 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
  • All Medicare Round 2021 Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (CBP) Contracts for off-the-shelf (OTS) back braces and OTS knee braces expire on December 31, 2023. Starting January 1, 2024, there will be a temporary gap in the DMEPOS CBP.
  • Round 2021 of the DMEPOS Competitive Bidding Program began on January 1, 2021 and includes off-the-shelf (OTS) back braces and OTS knee braces product categories.
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
  • 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.

Repairs to Orthotic

  • Labor and minor parts HCPCS Codes
    • L4205 - Repair of orthotic device, labor component, per 15 minutes
      • Claim line for code L4205 narrative must include:
        • Explanation of what is being repaired
    • L4210 - Repair of orthotic device, repair or replace minor parts (e.g., those without specific HCPCS codes). Supplier Price List (PL) amount is the amount the supplier is charging on the claim line.
      • Claim line for code L4210 narrative must include:
        • HCPCS code of item being repaired
        • Description of each item that is billed

Replacement

Replacement Same or Similar

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.

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:

  1. The benefit category for therapeutic shoes provisioned in the treatment of a diabetes-related condition(s) or
  2. The benefit category for leg braces (to which the shoes and related items would be considered for coverage as integral components of the leg brace).

Therapeutic Shoes vs Orthopedic Footwear -

Shoes, inserts, modifications covered in limited circumstances

  • Coverage includes select diabetic beneficiaries
  • Orthopedic shoes covered if integral part of covered leg brace
    • Search applicable brace codes in Orthopedic Footwear Policy Article A52481
    • Shoes incorporated into a brace must be billed by same supplier billing for brace
      • When initially providing brace
    • Shoes billed separately (i.e., not as part of brace) deny noncovered
  • Shoes/related modifications, inserts, heel/sole replacements, shoe transfers
    • Only covered when shoe is integral part of covered leg brace
    • Must be medically necessary for proper functioning of brace
    • Must be billed with KX modifier or will deny noncovered, statutorily excluded
Upper Limb Orthoses Coding

 

Resource

 

Last Updated Fri, 04 Aug 2023 12:49:27 +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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