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Orthotics

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 Aug 20, 2019

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.