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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
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
Off the Shelf vs 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  

 

Resource

 

Last Updated Thu, 07 Oct 2021 18:52:30 +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
Insufficient Documentation of Knee Orthoses to be Addressed in National Webinar on November 3, 2021 10/26/2021
Clinician Checklist and Knee Orthosis Documentation Checklist 10/06/2021
Knee Orthoses Webinar - November 11, 2021 10/05/2021
Lower Limb Prostheses Webinar - November 9, 2021 10/05/2021
Collaborative DME CERT Task Force - Knee Orthosis Webinar - November 3, 2021 10/05/2021
Service Specific Post-Payment Review: April 2021 - June 2021 07/29/2021
Service Specific Post-Payment Review: March 2021 - May 2021 06/30/2021
Service Specific Post-Payment Review: December 2020 - February 2021 04/12/2021
Policy Article Revisions Summary for March 11, 2021 03/11/2021
2020 Expansion Prior Authorization for Lower Limb Prosthetics Nationwide 12/07/2020
Ankle-Foot Orthosis (AFO) (HCPCS L4360 and L4361) Notification of Service Specific Post-Payment Review 12/07/2020
L1690 Prefabricated Bilateral Lumbo-sacral Hip Orthosis - Correct Coding 11/12/2020
Incorrect Use of HCPCS Codes for Custom Fit Orthotics 11/12/2020
L1005 - Tension Based Scoliosis Orthosis And Accessory Pads, Includes Fitting And Adjustment - Correct Coding 11/12/2020
Nationwide Expansion of the Condition of Payment Prior Authorization Program for Lower Limb Prosthetics 11/12/2020
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
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
Concentric Adjustable Torsion Joints - Correct Coding DMD   05/05/2017
LCD and Policy Article Revisions Summary for May 19, 2016 DMD   05/19/2016
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
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