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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

Tips

Topic Details
Custom Fabricated
  • 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
Custom Fabricated Item Cancelled
  • Include a claim narrative explaining reason for cancellation (e.g., death, cancelled, 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 cancelled or date of beneficiary death
Custom Fitted
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.

 

Resource

 

Last Updated Tue, 05 May 2020 18:54:30 +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.

paginationType noridian
Ankle-Foot Orthoses - Arizona-Type - Correct Coding - REVISED 10/22/2020
Correct use of Not Otherwise Specified L-codes for Orthoses and Prostheses - Billing Reminder 10/22/2020
Lower Limb Prosthesis Prior Authorization Webinar - November 11, 2020 10/14/2020
Ankle Foot Orthosis/Knee Ankle Foot Orthosis Webinar - November 4, 2020 10/06/2020
L1686 Prefabricated Hip Abduction Orthosis - Correct Coding 09/17/2020
Reminder - Prosthetic Feet and Additions to Lower Limb Extremity Prostheses - Coding Verification Review Requirement 09/03/2020
Same or Similar Denials for Orthoses and the Appeals Process 08/27/2020
Orthotics Same or Similar DME-on-Demand Tutorial Available 06/30/2020
RETIRED - Hand-Finger Orthoses - Use of CG Modifier - Revised DMD   05/21/2020
Condition of Payment Prior Authorization Program Expands to Include Lower Limb Prosthetics 03/23/2020
L3960 - Coding Verification review Requirement 03/13/2020
Targeted Probe and Educate Review Updates: October - December 2019 02/04/2020
Spinal Orthoses Targeted Probe and Educate Review Updates: April-June 2019 10/22/2019
Knee Orthoses Targeted Probe and Educate Review Updates: April-June 2019 10/22/2019
Ankle Foot/Knee-Ankle-Foot Orthosis (AFO/KAFO) Targeted Probe and Educate Review Updates: April-June 2019 10/22/2019
Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Revised - Now Available 07/05/2019
Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Revised 03/28/2019
Spinal Orthoses Targeted Probe and Educate Review Updates: October-December 2018 03/04/2019
Ankle-Foot Orthoses Targeted Probe and Educate Review Updates: October-December 2018 03/04/2019
Correct Coding - RT and LT Modifier Usage Change 02/28/2019
Spinal Orthoses Targeted Probe and Educate Review Updates: July - September 2018 12/31/2018
Ankle-Foot Orthosis Targeted Probe and Educate Review Updates: July - September 2018 12/31/2018
Knee Orthoses Targeted Probe and Educate Review Updates: July - September 2018 12/31/2018
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Update - Revised CR10838   12/13/2018
Dear Physician Letter - Documentation of Artificial Limbs and Braces (O&P) - November 2018 11/13/2018
LCD Revisions Summary for November 1, 2018 11/01/2018
Concentric Adjustable Torsion Joints - Correct Coding DMD   05/05/2017
LCD and Policy Article Revisions Summary for May 19, 2016 DMD   05/19/2016
Hand-Finger Orthoses - Use of CG Modifier - Revised DMD   03/10/2016
Correct Coding - IDEO and ExoSym Energy Storing AFO DMD   01/28/2016
Correct Coding - Ankle Orthoses, With or Without Joints, Prefabricated or Custom Fabricated Coding Verification Review DMD   12/03/2015
Lower Limb Prostheses - Draft Policy DL33787 DMD   11/05/2015
Lower Limb Prosthesis Draft LCD Bibliography DMD   08/03/2015
Draft Policies Release for Comment Bulletin Article DMD   07/16/2015
RETIRED - Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correction DMD   07/02/2015
Two New “K” Codes for Prefabricated Single and Double Upright Knee Orthoses Furnished Off-The-Shelf - Revised CR8839   09/03/2014
Additional States Requiring Payment Edits for DMEPOS Suppliers of Prosthetics and Certain Custom-Fabricated Orthotics - Update to CR3959 and CR8390 CR8730   05/21/2014