Orthotics - JD DME
Orthotics
Coverage
- Ankle-Foot/Knee-Ankle-Foot Orthosis Local Coverage Determination (LCD)
- Ankle-Foot/Knee-Ankle-Foot Orthosis Policy Article
- Knee Orthoses Local Coverage Determination (LCD)
- Knee Orthoses Policy Article
- Spinal Orthoses: TLSO and LSO Local Coverage Determination (LCD)
- Spinal Orthoses: TLSO and LSO Policy Article
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Checklist Ankle-Foot/Knee-Foot Orthosis [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Knee Orthoses - Custom and Prefabricated [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Checklist Spinal Orthoses [PDF] - Checklist to assist clinicians with coverage and documentation requirements
- Clinician Letter - Ankle-Foot/Knee-Ankle-Foot Orthoses [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Documentation of Artificial Limbs and Braces [PDF] - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Knee Orthoses [PDF] - Letter may be sent to clinicians to help obtain 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
Competitive Bid 2021
Competitive Bid 2021 includes off the shelf back and knee braces
- OTS back braces HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651
- OTS knee braces HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852
Prior Authorization
Prior Authorization for Orthoses
Please visit the above page for more information on prior authorization for orthoses
Requirements for Codes: L1832, L1833, L1851, L0648, and L0650
Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)
Prior Authorization Required:
- Nationwide as of 10/10/22
For these HCPCS codes requiring prior authorization there are special modifier requirements, in certain situations, to bypass the prior authorization process when billing the claim.
Claims will be subject to prepayment review for:
- Suppliers NOT in a CBA providing in acute/emergent situations utilize the ST modifier; or
- Practitioners/physicians who are also suppliers NOT in a CBA, so not subject to competitive bid rules requiring provision of the item on the same day as professional office visit, and who are providing a brace in an acute/emergent situation utilize the ST modifier; or
- Suppliers who are also practitioners/physicians or occupational therapists (OT)/physical therapists (PT) IN a competitive bid area and subject to providing item on same day as professional office visit utilize the KV or J5 modifier respectively.
Refer to chart below for HCPCS codes and requirements:
Documentation and Modifier Requirements to Bypass Prior Authorization
Acute/Emergent Situation NOT in Competitive Bid Area
Modifier appropriate for:
- Suppliers, or
- Practitioners/physicians who are also suppliers
- Acute/emergent necessity determined and documented by practitioner
HCPCS Code | Brace under Competitive Bid | Modifier |
---|---|---|
L1832 | No | ST |
L1833 | Yes | ST |
L1851 | Yes | ST |
L0648 | Yes | ST |
L0650 | Yes | ST |
Brace Provided at Office Visit for Immediate Use IN Competitive Bid Area
Modifier appropriate for:
- Physicians, practitioners, OTs, PTs who are also non-contract suppliers
- Furnishing brace to own patient at Part B billable office visit for immediate use – no exceptions
HCPCS Code | Brace under Competitive Bid | Modifier |
---|---|---|
L1832 | No | N/A |
L1833 | Yes | KV/J5 |
L1851 | Yes | KV/J5 |
L0648 | Yes | KV/J5 |
L0650 | Yes | KV/J5 |
ST Modifier - This modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary. The addition of this modifier will cause the claim to bypass the prior authorization program. Claims billed using modifier ST will be subject to 100% prepayment review.
- Suppliers providing in acute/emergent situations utilizing the ST modifier will bypass the prior authorization program.
- Practitioner/physicians who are also suppliers NOT in a competitive bid area may also utilize the ST modifier bypassing the prior authorization program.
J5 and KV modifiers - Physicians/OTs/PTs who are non-contract suppliers in a CBA furnishing OTS back and knee braces to their own patients during the Part B billable office visit must utilize the KV and J5 modifiers, respectively. In this case, the claim will bypass prior authorization review. 10% of these claims will be subject to prepayment review.
Note: The ST modifier is not to be used by practitioner/physicians or OTs/PTs who are non-contract suppliers in a competitive bid area furnishing OTS back and knee braces to their own patients.
Prior Authorization Timelines
Policy | Initial Review Decision Timeframe |
Expedited Review Decision Timeframe |
PAR Decision Valid |
---|---|---|---|
Orthoses | 5 business days | 2 business days | 60 days |
Tips
Topic | Details |
---|---|
AFO/KAFO Orthosis ICD-10-CM Codes that Support Medical Necessity |
|
Canceled Orders for Customized Items (salvage value) |
|
Coding Verification Review |
The only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL) Knee Orthoses
Spinal Orthoses
|
Competitive Bid |
|
Concentric Adjustable Torsion Joints | Find correct coding information for the Concentric Adjustable Torsion Joints |
Correct Billing Custom Fitted Orthotics Without Corresponding OTS Code |
|
Correct Coding Custom Fitted Without Corresponding OTS Code - DMD article |
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Custom Fabricated |
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DMEPOS Payments While Inpatient |
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Knee Orthosis ICD-10-CM Codes that Support Medical Necessity |
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Minimal vs More Than Minimal Self-Adjustment for Prefabricated Orthotics |
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Prefabricated Orthotics Off the Shelf vs Custom Fitted - DMD Article |
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Item Provided Prior to Surgery |
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A claim for code L4210 must include a description of each item that is billed in the narrative field on the claim. |
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RT/LT Modifiers |
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Upper Limb Orthoses Coding |
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Resource
Last Updated Tue, 10 Jan 2023 18:18:03 +0000
Related Articles
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.