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Orthotics

The Standard Written Order (SWO) requirements are in effect for dates of service January 1, 2020 and after.
Refer to the SWO page for the elements needed in this streamlined order.

Coverage

Documentation

Reviews/Audits

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

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Topic Details
Billing Custom Fitted Orthotics
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
Competitive Bid Single Payment Amount
  • Suppliers will find the Single Payment Amounts (SPAs) for the Healthcare Common Procedure Coding System (HCPCS) codes included in Round 2021 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program on the Competitive Bidding Program Contractor (CBIC) website. Existing payment amounts have been replaced with these SPAs for the selected HCPCS codes in certain competitive bidding areas (CBAs) when Round 2021 was implemented on January 1, 2021. For more information on how SPAs are calculated, please see the Lead Item Pricing fact sheet.
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 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.
Correct Coding Custom Fitted
DMEPOS Payments While Inpatient
Minimal vs More Than Minimal Self-Adjustment
  • 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. 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.
Off the Shelf vs Custom Fitted
  • If an orthosis needs only minimal self-adjustment for fitting at the time of delivery, it is considered off-the-shelf. However, if it 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 the article Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised
Item Provided Prior to Surgery
  • Prior to surgery, item can be provided and billed when it is medical necessary and coverage criteria is met and documentation is included in ordering physicians medical record. If there is no medical necessity until after surgery, do not provide item prior to surgery
Replacement
RT/LT Modifiers
  • Effective for claims with dates of service (DOS) on/after 03/01/19, 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 Mon, 06 Dec 2021 13:47:01 +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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