Tell us what you think

Chat bubble and question mark image

Your comments will help us improve our services.

Take the Prior Authorization Survey

Updates to Prior Authorization and F2F/WOPD Required Lists - Effective August 12, 2024

  • L1833 - Medicare will no longer require prior authorization, face-to-face (F2F) encounter, and Written Order Prior to Delivery (WOPD) for dates of service on or after August 12, 2024
  • L0631, L0637, L0639, L1843, L1845, L1951 added to Prior Authorization Required List effective for dates of service on or after August 12, 2024
  • L0635, L0636, L0638, L0639, L0640, L0651, L1845, and L1852 added to F2F/WOPD Required List effective for dates of service on or after August 12, 2024

Orthotics

Coverage and Documentation

Ankle-Foot/Knee-Ankle-Foot Orthoses (AFO/KAFO)

Knee Orthoses

Spinal Orthoses

Upper Limb

Reviews/Audits

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

Competitive Bid

The following codes were included in competitive bid; however, starting January 1, 2024, there is a temporary gap in the program:

  • 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

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

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

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 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.

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.

Repairs

View the Repairs page for requirements on orders, narratives on claims, and orthotic labor and minor parts HCPCS codes.

Replacement

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.

Last Updated Oct 14 , 2024

Related Articles

paginationType noridian
Articles Source Posted
Policy Article Revisions Summary for September 28, 2023 09/28/2023
L1681 Prefabricated Bilateral Hip Abduction Orthosis - Correct Coding 09/14/2023
Use Knee Orthoses Tutorials to Improve Your Understanding and Expertise 08/16/2023
Knee Orthoses Reasonable Useful Lifetime (RUL) Guidance in Policy Article A52465 07/20/2023
Policy Article Revisions Summary for July 20, 2023 07/20/2023
Ankle-Foot/Knee-Ankle-Foot Orthoses (AFO/KAFO) Top Denial - What to Do Next and How to Avoid It 07/19/2023
Temporary Gap Period for DMEPOS Competitive Bidding Program 07/19/2023
Clinician Checklist for Spinal Orthoses 05/09/2023
New Order and Face-to-Face Requirement for Certain Orthoses Now Active 05/02/2023
Certain Ankle-Foot/Knee-Ankle-Foot (AFO/KAFO) Orthotics Codes Have a New Requirement for the Order and Office Visit 05/01/2023
Ten Orthosis Codes Added to Required Face-to-Face Encounter and Written Order Prior to Delivery List 04/24/2023
Knee Orthosis (KO) Code L1843 Joins Other KO Codes on the Required Face-to-Face and Written Order Prior to Delivery List 04/20/2023
Knee Orthoses - Correct Documentation of Knee Instability 04/13/2023
Reminder About Providing Orthoses Prior to Surgery 04/13/2023
Attention Competitive Bid Suppliers Furnishing Off-the-Shelf (OTS) Knee and Back Braces as a Non-Contract Physician or Other Treating Practitioner, Physical Therapist, or Occupational Therapist 03/20/2023
New Documentation and Clinician Checklists for Upper Limb Orthoses 03/06/2023
Reminder When Providing Orthoses Prior to Surgery 02/27/2023
Ten Orthosis Codes Added to Required Face-to-Face Encounter and Written Order Prior to Delivery List 02/21/2023
Prior Authorization (PAR) Is Required Nationwide for Five Orthotics Codes 12/29/2022
Billing for Custom Fitted Orthotics When No Custom Fitting Is Completed With No Off-The-Shelf Equivalent 12/27/2022
Use Prior Authorization Resources for Orthoses 11/03/2022
Billing for Custom Fitted Orthotics When No Custom Fitting Is Completed With No Off-the-Shelf Equivalent 10/26/2022
Providing Items Prior to Surgery 10/25/2022
Resources to Help Bill Knee Orthotics Correctly 10/25/2022
Phase 3 of Prior Authorization is Right Around the Corner 09/28/2022
Find Upper Limb Correct Coding in a Joint Medical Director Article 09/13/2022
Billing for Orthotics Requiring Prior Authorization in Acute Situations and Under Competitive Bidding 04/22/2022
CMS Expands its Prior Authorization Program for Orthotics and Power Mobility 04/05/2022
2022 Expansion for Face-to-Face (F2F) and Written Order Prior to Delivery (WOPD) 04/01/2022
Code Verification Review Requirement for Lower Limb Orthoses (L1832, L1833, and L1851) and Lumbar Sacral Orthoses (L0648 and L0650) 03/31/2022