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:

• Suppliers providing in Acute/Emergent situations where a two-day expedited review would delay care and risk the health or life of the beneficiary can utilize the ST modifier to bypass the prior authorization program. These claims will be subject to 100% prepayment review.
• Practitioner/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, providing in Acute/Emergent situations where a two-day expedited review would delay care and risk the health or life of the beneficiary can utilize the ST modifier and bypass the prior authorization program. These claims will be subject to 100% prepayment review.
• For a physician/practitioner or occupational therapist (OT)/physical therapist (PT) or hospital furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), and subject to providing item on same day as professional office visit, must bill with modifiers KV, J5 or J4, respectively conveying that the DMEPOS item is needed immediately. When submitted with one of these modifiers, 10% of claims will be subject to prepayment review.

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.)

• J5 - Physical therapists and occupational therapists
• KV - Physicians and other treating practitioners
• J4 - Hospital

• 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.

• 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.

• Refer to the Correct Billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off the Shelf Equivalent webpage for more information and utilize the Off-The-Shelf or Custom-Fitted Orthotic Lookup Tool

• Refer to the coding and billing of custom fitted orthotics that do not have a corresponding off-the-shelf equivalent article by the Joint DME MAC and PDAC. Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding

• 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
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• 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.

• Want to know more about DMEPOS Deliveries before Inpatient Discharge? Please refer to the Medicare DMEPOS Payments While Inpatient MLN Fact Sheet

• 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.

• 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

• Items can be provided and billed prior to surgery when item is medically necessary, prior to surgery, coverage criteria is met, and documentation is included in ordering physician’s medical record. If there is no medical necessity until after surgery, item should not be provided until after the surgery has been performed and medical need exists.

• 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 specific LCD/PA specify otherwise
• See Medical Director written Billing Instructions - LSO and TLSO
• See Medical Director written Orthoses: Replacement of Components Clarification - Republished

• 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.

• 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.