Orthotics

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Repair and Replacement O&P - 09/10/19
Spinal Orthosis - 09/18/19

Coverage

Documentation

AFO/KAFO Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Knee Orthosis Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation
Spinal Orthosis Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required 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	Certified orthotist or an individual who has equivalent specialized training in making substantial modifications to orthosis can perform substantial modifications for a custom fitted prefabricated orthotic. (e.g., physician, treating practitioner, physical therapist or occupational therapist in compliance with all applicable federal and state licensure and regulatory requirements). See the article Correct Coding - Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Revised
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	Allowed due to loss, theft, or irreparable damage or when reasonable useful lifetime 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
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

CMS Off-the-Shelf Orthotic HCPCS Codes

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.