Orthotics - JD DME
Orthotics
- Coverage and Documentation
- Reviews/Audits
- Custom Fabricated
- Custom Fit Orthotics Without Corresponding Off-the-Shelf Code
- Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
- Prior Authorization
- Tips
Coverage and Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Letter - Documentation of Artificial Limbs and Braces
Ankle-Foot/Knee-Ankle-Foot Orthoses (AFO/KAFO)
- Local Coverage Determination (LCD)
- Policy Article (includes covered ICD-10 codes)
- Clinician Checklist
- Clinician Letter
- Documentation Checklist
Knee Orthoses
- Local Coverage Determination (LCD)
- Policy Article (includes covered ICD-10 codes)
- Clinician Checklist - Custom and Prefabricated
- Clinician Letter
- Documentation Checklist
Spinal Orthoses
Upper Limb
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Custom Fabricated
View Custom Items for information on medical necessity and billing not otherwise classified (NOC) codes.
Custom Fit Orthotics Without Corresponding Off-the-Shelf Code
- Correct Billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off-the-Shelf Equivalent
- Refer to the Off-The-Shelf or Custom-Fitted Orthotic Lookup Tool to determine the correct HCPCS code to bill when providing a custom fit code but no custom fitting is completed. This includes adding the policy specific required modifier and the LT or RT modifiers.
- Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding - Revised
- Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised
- Off-The-Shelf or Custom-Fitted Orthotic Lookup Tool
Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
The following HCPCS codes require a face-to-face encounter and a written order prior to delivery:
- L1832, L1833, L1851, L0648, L0650, L3960, L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, L2036
- Note: L1833 requires a F2F encounter and WOPD for dates of service prior to August 12, 2024
- L0635, L0636, L0638, L0639, L0640, L0651, L1845, and L1852 - Effective for dates of service on or after August 12, 2024
Prior Authorization
The following HCPCS codes require a prior authorization: L1832, L1833, L1851, L0648, and L0650.
- Note: L1833 requires a prior authorization for dates of service prior to August 12, 2024
- L1843, L1845, L1951, L0631, L0637, and L0639 - Effective for dates of service on or after August 12, 2024
When prior authorization is required for an item, but the medical need is not established until after surgery, or in an acute or emergent situation, prior authorization should not be required. In such cases, suppliers should provide the brace and append the ST modifier to the claim line. The ST modifier indicates that the item was provided in an acute or emergent situation, thereby bypassing the prior authorization process. Please note that these claims will be subject to prepayment review.
Tips
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. Follow the guidelines for Canceled Orders for Customized Items to facilitate the reimbursement process. Please refer to the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 20.3 for more information.
Coding Verification Review
View Coding Verification Review for a list of HCPCS codes able to be billed that have received a written coding verification review (CVR) by the Pricing, Data Analysis, and Coding (PDAC) contractor.
Concentric Adjustable Torsion Joints
Find correct coding information for the Concentric Adjustable Torsion Joints.
DMEPOS Payments While Inpatient
Refer to the Medicare DMEPOS Payments While Inpatient MLN Fact Sheet for information on inpatient payments, deliveries before inpatient discharge, and interruptions in period of continuous use.
Item Provided Prior to or After Surgery
- Medical need prior to surgery - Items can be provided and billed prior to surgery when item is medically necessary and the brace is required to be worn prior to surgery, coverage criteria is met, and documentation to substantiate the need is included in ordering physician's medical record.
- Medical need after surgery - If there is no medical need to wear the brace until after surgery, item should not be provided until after the surgery has been performed and medical need exists.
Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthoses
- 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.
Repairs
View the Repairs page for requirements on orders, narratives on claims, and orthosis labor and minor parts HCPCS codes.
Replacement
- 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 LCD/PA specify otherwise.
- See Medical Director written Billing Instructions - LSO and TLSO
- See Medical Director written Orthoses: Replacement of Components Clarification - Republished
RT/LT Modifiers
Suppliers must bill each item on two separate claim lines using the RT and LT modifiers and one unit of service (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.
Therapeutic Shoes vs Orthopedic Footwear
Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. View Therapeutic Shoes vs Orthopedic Footwear for more information.
Upper Limb Orthoses 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 revised) for additional information.
