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Take the Prior Authorization Survey

Modifier Changes Effective 01/01/24

Effective for dates of service 01/01/24 and after, competitive bid modifiers KV, J4, and J5 are no longer used. Follow the prior authorization process for claims previously provided in a competitive bid area. For more information, see Prior Authorization and Pre-Claim Review Initiatives on the CMS website.

Orthotics

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Providing Custom Fit as Off-the-Shelf With no Other Alternative - Exception

Competitive Bid 2021 Includes Off-the-Shelf Back and Knee Braces

Gap period begins for dates of service (DOS) January 1, 2024 and after.

  • OTS back brace HCPCS codes: L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, and L0651
  • OTS knee brace HCPCS codes: L1812, L1830, L1833, L1836, L1850, L1851, and L1852

Face-to-Face Encounter and Written Order Prior to Delivery (WOPD)

  • Required for codes: L1832, L1833, L1851, L0648, L0650, and L3960
    • Effective 4/13/22
  • Required for codes: L0631, L0637, L1843, L1932, L1940, L1951, L1960, L1970, L2005, L2036
    • Effective 4/17/23

Prior Authorization Required for Orthoses

  • Required for codes: L1832, L1833, L1851, L0648, and L0650
    • Effective nationwide 10/10/22

Prior Authorization Timelines

Policy Review
Decision Timeframe
Expedited Review
Decision Timeframe
PAR Decision Valid
Orthoses 5 business days 2 business days 60 days

Situations to Bypass Prior Authorization (Prior to DOS 01/01/2024)

Process Change

For dates of service beginning January 1, 2024, and after, there is a temporary gap period in the DMEPOS Competitive Bidding Program (CBP) for off-the-shelf back and knee braces. During the gap period, the prior authorization requirements for HCPCS codes L0648, L0650, L1833, and L1851 change and the competitive bid modifiers KV, J4, and J5 are no longer used. Treating practitioners now have the option to follow the prior authorization process with the standard timeframe of review, request an expedited review, or utilize the ST modifier, indicating acute/emergent need. For more information, refer to the Timeline and Updates section of the Prior Authorization and Pre-Claim Review Initiatives webpage on the CMS website. This process change only affects non-contract competitive bid suppliers who are practitioners/physicians, physical therapists, and occupational therapists.

In certain situations, there are special modifiers that will cause the claim to bypass prior authorization when billing a claim. These claims will be subject to prepayment review.

  • All Medicare physicians or other treating practitioners IN a Competitive Bid Area (CBA), who are not a CB contracted supplier providing a brace in an acute or emergent situation who are enrolled as Medicare DMEPOS suppliers must append the KV or J5 modifier to the claim
    • Practitioners and physicians must append KV modifier to claim line in these circumstances
    • Occupational therapists (OT)/physical therapists (PT) must append J5 modifier to claim line in these circumstances

Refer to charts below for modifier requirements when bypassing prior authorization

HCPCS Code Requiring Prior Authorization Modifier Acute/Emergent Situations
All DME Suppliers
Example: L1832ST
L1832 ST
HCPCS Code Requiring Prior Authorization Brace Under Competitive Bid Modifier Acute/Emergent Situations
All DME Suppliers
Example: L1833ST
(Valid DOS 1/1/2024 and after)
EXCEPTION
Modifier Physicians/Practitioners
Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception
Example: L1833KV
(Only valid through DOS 12/31/2023)
EXCEPTION
Modifier OT/PT
Providing Brace in a Competitive Bid Area Under Non-Contract Supplier Exception
Example: L1833J5
(Only valid through DOS 12/31/2023)
L1833 Yes ST KV J5
L1851 Yes ST KV J5
L0648 Yes ST KV J5
L0650 Yes ST KV J5

Note: More information about Non-Contract Supplier Exceptions can be found within the Tips section of the Competitive Bidding Webpage.

Tips

Topic Details
AFO/KAFO Orthosis
ICD-10-CM Codes that Support Medical Necessity
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.
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

  • L1845 - Effective for claims with dates of service on or after July 01, 2008
  • L1852 - Effective for claims with dates of service on or after January 1, 2017
  • L1832, L1833 and L1851 - Effective for claims with dates of service on or after October 10, 2022

Spinal Orthoses

  • L0450, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0625, L0626, L0627, L0628, L0630, L0631, L0633, L0635, L0637, L0639 - Effective for claims with dates of service on or after July 1, 2010
  • L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651 - Effective for claims with dates of service on or after January 1, 2014
  • There are two categories of custom fabricated spinal orthoses (codes L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, and L0640)
  • Orthoses that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the beneficiary.
    • Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC web site
Competitive Bid
(Gap period begins 01/01/2024)
  • All Medicare Round 2021 Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (CBP) Contracts for off-the-shelf (OTS) back braces and OTS knee braces expire on December 31, 2023. Starting January 1, 2024, there will be a temporary gap in the DMEPOS CBP.
  • Round 2021 of the DMEPOS Competitive Bidding Program began on January 1, 2021 and includes off-the-shelf (OTS) back braces and OTS knee braces product categories.
Concentric Adjustable Torsion Joints Find correct coding information for the Concentric Adjustable Torsion Joints
Correct Coding and Billing Custom Fitted Orthotics Without Corresponding OTS Code
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 Not Otherwise Classified (NOC) custom fabricated - If the item is custom fabricated and does not have a specific HCPCS code a narrative must be added to the claim.
    • Narrative added to claim:
      • Description of the item or service
      • Manufacturer name
      • Product name, model name and number
      • Supplier Price List (PL) amount (this is the same amount billed on the claim line)
      • HCPCS code of related item (if applicable)
      • If Repair part, HCPCS code of item being repaired
  • If claim is denied, request redetermination with all documentation to support medical necessity
    • Medical necessity for item (medical records)
    • If item is custom-fabricated, provide complete and clear description of item including:
      • What makes item unique
      • Breakdown of charges (materials and labor)
  • See DMD article 3-D Printed Orthotic Devices - Correct Coding
DMEPOS Payments While Inpatient
Knee Orthosis
ICD-10-CM Codes that Support Medical Necessity
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 - DMD Article
  • 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)
Item Provided Prior to Surgery
  • 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.
  • 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.

Repairs to Orthotic

  • Labor and minor parts HCPCS Codes
    • L4205 - Repair of orthotic device, labor component, per 15 minutes
      • Claim line for code L4205 narrative must include:
        • Explanation of what is being repaired
    • L4210 - Repair of orthotic device, repair or replace minor parts (e.g., those without specific HCPCS codes). Supplier Price List (PL) amount is the amount the supplier is charging on the claim line.
      • Claim line for code L4210 narrative must include:
        • HCPCS code of item being repaired
        • Description of each item that is billed

Replacement

Replacement Same or Similar

RT/LT Modifiers
  • 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.

Medicare Coverage for Shoes - Correct Coding - Revised

Therapeutic Shoes vs Orthopedic Footwear

Medicare has limited coverage provisions for shoes, inserts, and shoe modifications used by beneficiaries. In order to be eligible for coverage, such items must qualify in either:

  1. The benefit category for therapeutic shoes provisioned in the treatment of a diabetes-related condition(s) or
  2. The benefit category for leg braces (to which the shoes and related items would be considered for coverage as integral components of the leg brace).

Therapeutic Shoes vs Orthopedic Footwear -

Shoes, inserts, shoe transfer, modifications covered in limited circumstances

  • Coverage includes select diabetic beneficiaries
  • Orthopedic shoes covered if integral part of covered leg brace
    • Search applicable brace codes in Orthopedic Footwear Policy Article A52481
    • Shoes incorporated into a brace must be billed by same supplier billing for brace
      • When initially providing brace
    • Shoes billed separately (i.e., not as part of brace) deny noncovered
  • Shoes/related modifications, inserts, heel/sole replacements, shoe transfers
    • Only covered when shoe is integral part of covered leg brace
    • Must be medically necessary for proper functioning of brace
    • Must be billed with KX modifier or will deny noncovered, statutorily excluded
  • Shoe Transfers to beneficiary owned item
    • All suppliers are allowed to provide replacement shoes or braces when the shoe is an integral part of a covered leg brace. When billing the transfer, follow the orthopedic footwear policy article for shoe transfers. A KX modifier must be added to the code. An order is not required for the transfer of a shoe to a brace
Upper Limb Orthoses Coding

Resource

Last Updated Feb 20 , 2024

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