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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
DMEPOS Payments While Inpatient
Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthotics
  • 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.
Prefabricated Orthotics

Off the Shelf vs Custom Fitted
  • 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
Item Provided Prior to Surgery
  • 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.
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 Wed, 29 Dec 2021 18:06:55 +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
Knee Orthoses Webinar - March 3, 2022 01/25/2022
Is That Ankle-Foot/Knee-Ankle-Foot Orthosis (AFO/KAFO) Off-the-Shelf (OTS) or Custom Fitted (CF)? 01/18/2022
Service Specific Post-Payment Reviews 01/14/2022
DME MAC Collaborative Orthoses Webinar Webinar - February 24, 2022 01/11/2022
Repairs and Replacements Orthotics and Prosthetics Webinar - February 3, 2022 12/28/2021
Same or Similar Orthotics Webinar - February 2, 2022 12/28/2021
Do You Have a Question About a Prefabricated Orthotic and How It Should Be Coded and Billed? 12/01/2021
Correct Coding of Elbow, Shoulder, Shoulder-Elbow-Wrist-Hand and Shoulder- Elbow-Wrist-Hand-Finger Braces (Orthoses) 11/18/2021
Correct Coding of Finger, Hand, Hand-Finger and Wrist-Hand- Finger Braces (Orthoses) - Revised 11/18/2021
Off-the-Shelf vs Custom-Fitted Orthotic Lookup Tool - Now Available 11/02/2021
Service Specific Post-Payment Reviews 10/20/2021
Clinician Checklist and Knee Orthosis Documentation Checklist 10/06/2021
Service Specific Post-Payment Review: December 2020 - February 2021 03/30/2021
Policy Article Revisions Summary for March 11, 2021 03/11/2021
2020 Expansion Prior Authorization for Lower Limb Prosthetics Nationwide 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