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 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
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Competitive Bid 2021
Competitive Bid 2021 includes off the shelf back and knee braces
- OTS back braces HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651
- OTS knee braces HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852
Prior Authorization
Prior Authorization for Orthoses
Please visit the above page for more information on prior authorization for orthoses
For Codes: L1832, L1833, L1851, L0648, and L0650
F2F and WOPD Required Effective: 04/13/22
Prior Authorization Required:
- 04/13/22: NY, IL, FL, and CA
- 07/12/22: MD, PA, NJ, MI, OH, KY, TX, NC, GA, MO, AZ, and WA
- 10/10/22: Nationwide
For these HCPCS codes requiring prior authorization there are special modifier requirements, in certain situations, to bypass the prior authorization process when billing the claim.
Claims will be subject to prepayment review for:
- Suppliers providing in Acute/Emergent situations utilizing the ST modifier; or
- Practitioners/physicians who are also suppliers NOT in a competitive bid area, so not subject to competitive bid rules requiring provision of the item on the same day as professional office visit, and who are providing a brace in an acute/emergent situation utilizing the ST modifier; or
- Competitive bid suppliers who are also practitioners/physicians or occupational therapist (OT)/physical therapist (PT) IN a competitive bid area and subject to providing item on same day as professional office visit utilizing the KV or J5 modifier.
Refer to chart below for HCPCS codes and requirements:
Documentation and Modifier Requirements to Bypass Prior Authorization
HCPCS Code |
Brace under Competitive Bid |
Modifier Acute/Emergent Situations with suppliers, or Practitioner/physicians who are also suppliers NOT in a competitive bid area |
Modifier Suppliers who are a physician/practitioner or OT/PT in a competitive bid area |
---|---|---|---|
L1832 | No | ST | N/A |
L1833 | Yes | ST | KV/J5 |
L1851 | Yes | ST | KV/J5 |
L0648 | Yes | ST | KV/J5 |
L0650 | Yes | ST | KV/J5 |
ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary, suppliers may opt to bypass the prior authorization program. These claims will be billed using modifier ST and will be subject to 100% prepayment review.
- Suppliers providing in Acute/Emergent situations utilizing the ST modifier will bypass the prior authorization program. These claims will be subject to 100% prepayment review. Documentation will be requested to substantiate the acute/emergent situation.
- Practitioners/physicians who are also suppliers and NOT in a competitive bid area who are providing a brace in an acute/emergent situation are required to use the ST modifier to bypass the prior authorization program. These claims will be subject to 100% prepayment review. Documentation will be requested to substantiate the acute/emergent situation.
J5 and KV modifier - Physicians/OT/PT who are non-contract suppliers furnishing OTS back and knee braces to their own patients will utilize the KV and J5 modifiers, respectively. In this case, the claim will bypass prior authorization review. 10% of these claims will be subject to prepayment review. (The ST modifier is not to be used by practitioner/physicians or OT/PTs who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.)
Prior Authorization Timelines
Policy | Initial Review Decision Timeframe |
Expedited Review Decision Timeframe |
PAR Decision Valid |
---|---|---|---|
Orthoses | 5 business days | 2 business days | 60 days |
Tips
Topic | Details |
---|---|
Billing for Orthotics Requiring Prior Authorization in Acute/Emergent Situations and Under Competitive Bidding Program |
CMS has given special consideration for acute situations for orthotics. Prior authorization requirements will be suspended for HCPCS codes L0648, L0650, L1832, L1833, and L1851 for the following criteria:
ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary. J4, J5 and KV modifier – Physicians, occupational, physical therapists, and hospitals who are non-contract suppliers in a competitive bid area who provide OTS back and knee braces to their own patients will utilize the KV, J5, and J4 modifiers, respectively. (The ST modifier is NOT to be used by Physician/Practitioner or OT/PT who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.)
|
Canceled Orders for Customized Items (salvage value) |
|
Competitive Bid |
|
Concentric Adjustable Torsion Joints | Find correct coding information for the Concentric Adjustable Torsion Joints |
Correct Billing Custom Fitted Orthotics |
|
Correct Coding Custom Fitted |
|
Custom Fabricated |
|
DMEPOS Payments While Inpatient |
|
Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthotics |
|
Prefabricated Orthotics Off the Shelf vs Custom Fitted |
|
Item Provided Prior to Surgery |
|
Replacement |
|
RT/LT Modifiers |
|
Upper Limb Orthoses Coding |
|
Resource
Last Updated Fri, 29 Jul 2022 17:31:47 +0000
Related Articles
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.