ACT Questions and Answers - Orthotics and Prosthetics - November 12, 2020

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Teleconference (ACT) - Orthotics and Prosthetics. Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for one supplier, Noridian addressed directly with the supplier. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

Pre-Submitted Questions

Q1. Is a proof of delivery or detailed written order (DWO) required for noncovered items? Example: HCPCS code A4467
A1. As a DMEPOS supplier, proof of delivery is a supplier standard and therefore required. The A4467 (belt, strap, sleeve, garment, or covering, any type) does not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. As such, this code would be denied as noncovered (no Medicare benefit). If the item will be billed to Medicare, a standard written order (SWO) is required.

Q2. What are CMS’ unpublished rules? Where can they be found in regard to a claim denial?
A2. CMS has what are called medically unlikely edits (MUE). An MUE for a HCPCS code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Locate published information on the CMS website.

Q3. Are there guidelines that can be found to follow regarding upper extremity orthotics and prosthetics?
A3. Yes, view DME on Demand self-paced tutorials under the Education and Outreach webpage and the article “Correct Billing for Upper Limb Prosthesis with L6895 instead of L7499”:

Q4. Will the DMEPOS fee schedule be updated for the fourth quarter by end of the year?
A4. Noridian publishes fee schedule information when provided by CMS. A link to the fourth quarter fee schedule is available on the Noridian website:

Q5. Can Noridian provide more information on same/similar and the five-year reasonable useful lifetime (RUL) for orthotic items?
A5. In the absence of specific guidance, the RUL will always be five years.

Q6. What are the frequency and limitations on prosthetic supplies such as socks and liners in addition to strap replacement and labor on ankle foot orthoses?
A6. Socks and liners fall under the non-consumable refill requirements. No more than two of the same inserts are allowed per individual prosthesis at the same time. In reference to labor for ankle foot orthotics, the labor is billed in 15-minute increments and may only be for the time involved in the actual repair of the item.

Q7. Regarding requirements of post-operative braces, can the brace be provided before discharge or after?
A7. If the surgery itself will create the need for the brace, the brace cannot be delivered prior to the surgery as no need exists. A brace needed following surgery may be delivered within two days of discharge for use in the home.

Q8. How do suppliers get access to check same and similar for all jurisdictions?
A8. Each DME Medicare Administrative Contractor (MAC) jurisdiction has a portal that suppliers may register to utilize for checking same/similar equipment.

Q9. When will prior authorization be implemented for lower limb prosthetics?
A9. Currently condition of payment prior authorization for lower limb prosthetics is limited to California, Michigan, Pennsylvania, and Texas. Note that Noridian has another lower limb prosthesis prior authorization webinar scheduled for December 3, 2020.

Sub-note: National requirement for prior authorization began for lower limb prosthetics (LLP) on December 1, 2020.

Q10. Can a nurse practitioner (NP)/ physician assistant (PA) do the face-to-face for an ankle-foot orthosis (AFO) or a knee brace and if so, does the note have to be co-signed by an MD or DO?
A10. Yes, an NP/PA can do the face-to-face for an AFO or a knee brace. Medicare does not require a co-signature for NP or PA notes; however, state regulations may differ so be sure to check the state regulations regarding co-signing of NP or PA notes.

Questions Received During ACT

Q1. We have beneficiaries that live quite a distance from our office. After December 1, will Medicare frown on us if we do the casting but stop after that until we go through the preauthorization process since we can’t submit the preauthorization before we know what the beneficiary needs?
A1. The prior authorization request can be submitted as early as November 17, 2020, even though the program doesn’t start until December 1. Suppliers can obtain the information about the beneficiary, manufacturing, etc., but the item can’t be delivered and billed prior to December 1.

Q2. Regarding an off-the-shelf (OTS) spinal orthotic L0625, I’ve seen RUL of five years. The beneficiary is having problems with the Velcro due to weight changes. The brace fits her, but the Velcro strapping isn’t functioning from daily wear and tear. Since this isn’t something we can repair, how do we address this?
A2. The item is expected to last five years and the RUL doesn’t allow for daily wear and tear. If it can’t be repaired, then it may be an opportunity for an Advance Beneficiary Notice of Noncoverage (ABN).

Q3. Regarding competitive bid, we have a contract for off-the-shelf (OTS) in certain areas, but one of our beneficiaries doesn’t live in one of these areas. Can we provide the beneficiary with a brace? Is the reimbursement based on competitive bid or non-competitive bid?
A3. Reimbursement and available suppliers are determined by the zip code in which the beneficiary resides.

Q4. I submitted a claim with the NU and KX modifiers. I also used a place of service of 04, shelter, but I’m receiving a denial. Are these modifiers and place of service code valid?
A4. The NU modifier is not needed on a knee orthosis. The place of service (POS) for DMEPOS claims is considered the location where a beneficiary will primarily use the item. If that location is a homeless shelter (POS 04), that would be acceptable.

Q5. We had a claim that was denied due to the physician referred to a brace by a brand name, Richie brace. It’s a custom ankle/foot orthosis (AFO) with two classifications and eight variations. I’m not aware of any AFOs needing to be classified with the Pricing, Data Analysis and Coding (PDAC) contractor. Why would this not be overturned on review?
A5. Follow the product classification list on PDAC for exact coding. An appeal can be submitted to demonstrate the item delivered was not on the product classification list. Also, be sure the Standard Written Order (SWO) fully details all the components of the orthosis to assist in confirming what was delivered.

Q6. For an established bi-lateral amputee, would Noridian allow for an order for refills/replacement from a Doctor of Podiatric Medicine (DPM)? Technically the DPM can order but since the beneficiary doesn’t have feet, is it practical to see this practitioner anymore?
A6. A podiatrist would not have a need to be treating a beneficiary in this circumstance. Once the beneficiary does not have a foot, the reason to see the DPM would be outside the scope of practice.

Q7. Can a PA perform the face-to-face for a brace?
A7. Yes, Medicare allows a PA and NP to treat and prescribe bracing.

Q8. If we have a beneficiary with a Health Maintenance Organization (HMO), does competitive bid apply?
A8. Medicare Fee-for-Service is the only Medicare program affected by competitive bid. If a beneficiary has a commercial insurance, it is not affected.

Q9. For initial claims, documentation for prosthetics is good for the lifetime of the device. If an adjustment is needed, what documentation is required?
A9. Repairs do not require a separate new order; however, continued medical need must be met through an order by the treating physician or medical records documenting the beneficiary’s condition within the preceding 12 months. This information is in the Standard Documentation Article under Active Local Coverage Determinations (LCDs), the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, and the Supplier Manual, Chapter 5, DMEPOS, Repairs and Replacements:

Follow-Up Question: Can the records be from the prosthetist or treating physician?
Noridian Response: The records need to come from the person treating the beneficiary (physician, NP, etc.)

Follow-Up Question: Do we need the prescription before doing the repair or can we send a SWO to the physician prior to billing?
Noridian Response: A new prescription is not required specifically for the repair. However, the supplier completing the repair will want to be sure that the beneficiary meets the coverage criteria for the item being repaired.

Q10. If we have the original order for a prosthesis and three years later, there is movement inside the socket. Do we need an order from a physician prior to building the inside of the socket?
A10. Repairs do not require a new order; however, there is a requirement for evidence of ongoing medical need for the device. If the beneficiary hasn’t seen their practitioner in the last 12 months, a new order would indicate the need and usage of the prosthesis. This can also be demonstrated in the medical records.

Q11. I have a husband and wife that go to the same physician for diabetic shoes and inserts. I submitted a request to the physician for the Statement of Certifying Physician and the letter of physician documentation requirements. They completed the Statement of Certifying Physician, but the medical records do not say anything regarding diabetic shoes or diabetes. Can I request that information from their podiatrist or does it have to be from their MD?
A11. Suppliers may request the records from the Doctor of Podiatric Medicine (DPM) that conducted the foot exam and send to the Certifying Physician for them to initial, date (prior to signing the certification statement), and indicate agreement on the medical records of that in-person visit.

Written Questions Received During ACT

Q1. Will Medicare consider reimbursement for a custom molded shoe, even if the beneficiary is not diabetic and the shoe will not be attached to a brace? Should we submit for a prior authorization?
A1. There is not a prior authorization for these items. The custom molded shoes are not covered under the Therapeutic Shoe policy unless the beneficiary is a diabetic and the shoe would not be covered if it is not attached to a brace.

Q2. In reference to L5673 (locking liners), the LCD states "are allowed per individual prosthesis at the same time". What does Noridian mean by the same time? Is this in the same year?
A2. This means the same date of service.

Q3. What is the frequency in a year that a beneficiary can get prosthetic socks (L8420)?
A3. Per the MUE lookup tool on the CMS website, the limit is 24 in a year, only three per date of service. Please note that these are considered non-consumable refills so the refill requirements must be followed.

Q4. Can suppliers do prosthetic authorization requests on the website?
A4. Yes, prior authorizations can be completed through the Noridian Medicare Portal (NMP).

Q5. As a provider, are we permitted to charge beneficiaries for a house call when they are not able to come into the office?
A5. No this would not be appropriate as a DMEPOS supplier.

Q6. The wear and tear replacement does not apply to the locking liners but the wear and tear does apply to orthotics RUL? It was previously stated that the RUL is five years and the wrist brace cannot be replaced due to the five-year rule, but when the liner has wear and tear, it is permitted to be replaced as medically necessary.
A6. Prosthetics do not have the same RUL as orthotics. Please see the lower limb prostheses local coverage determination (LCD)

Q7. It was stated in a previous slide that liners fall under non-consumable refill requirements. We were under the impression that prosthetic liners were only two per side per year but am I to understand that liners are limited to just two per time of delivery if a face-to-face exam states worn out or lost?
A7. Liners are considered a non-consumable item and must be treated as a refill. The treating practitioner should identify the quantity on the SWO, and the beneficiary’s medical record should support the frequency. For more information, see the Standard Documentation Policy Article for refill requirements of non-consumable items.

Q8. Am I understanding correctly that in order to provide repairs to a prosthesis, we would need a prescription on file from their MD (or equivalent) within 12 months of that date of repair? In order to bill for that repair, we would then send the SWO to the MD after the repair has been made?
A8. Repairs themselves do not require an order, however the supplier providing the repair must know that there is an order for that item. If it is not in their files, one would need to be obtained. Evidence of on-going medical need is required every twelve months. Either a new order or the medical record would meet that requirement.

Q9. Is there any movement on the same/similar issues with OTS devices like a walking boot, L4361 versus custom molded device L1970? There should be something around devices for acute injury or diagnosis versus chronic condition.
A9. We have not been given word on any changes to the same/similar charts, however there is consideration through the appeals process for these items when there is a change in medical condition.

Q10. What is the difference between a SWO and a DWO? When is one more appropriate than the other?
A10. The SWO replaced the DWO as of January 1, 2020 and has fewer element requirements than the DWO. Suppliers may continue to utilize their existing order if it has all elements required for a SWO.

Q11. Is there ever a case when it's mandatory for a physician to sign off on a physical therapist’s (PT) clinicals/justification for an orthotic or prosthetic item?
A11. Both the physician and the physical therapist’s records are part of the medical record . The PT records do not require co-signature.

Q12. What is PDAC? Is this in effect for New York?
A12. PDAC stands for Pricing, Data Analysis and Coding. It is nationwide and Palmetto is the contractor. They provide direction on coding and pricing for all durable medical equipment, orthotics, prosthetics and supplies (DMEPOS).

Q13. What is PECOS and why does a physician need to be PECOS-certified?
A13. PECOS is the Medicare Provider Enrollment, Chain and Ownership System. A physician must be registered with PECOS in order to bill Medicare. If they are not registered, their claims will deny. There is a Dear Clinician Letter on the Noridian website that explains PECOS.

Q14. If the treating practitioner is not PECOS-certified can the DME supplier still fulfill an order and bill successfully or will the claim be denied since the treating practitioner isn’t PECOS-certified?
A14. The claim would be denied if the practitioner is not PECOS-certified.

Q15. Are the notes from a certified orthotist or prosthetist part of the medical record?
A15. These are not considered part of the medical record.

Q16. For outpatient surgery, can the brace be provided up to two days prior to surgery?
A16. The brace needs to be provided once the need exists, this would require the surgery to have taken place prior to provision of the item, if the brace is only required post-surgery.

Q17. Can we bill replacement liners with the RB modifier if the physician orders the items?
A17. No, the RB would not be appended to replacement liners. The RB modifier is utilized for a replacement of a component of DME as part of a repair. For example, when billing a replacement accessory for the main piece of equipment, supplier must bill with the RB modifier and provide a detailed explanation as to why the accessory is being replaced.

Q18. What is the RUL for a spinal orthosis?
A18. The RUL for all spinal orthosis is five years.

Q19. When a beneficiary receives a custom Ankle, Foot Orthosis (AFO) and the clinicals do not fully support the custom criteria, can we use a GY modifier in this case to get a patient responsibility (PR) denial?
A19. An Advance Beneficiary Notice of Noncoverage (ABN) should be obtained in this scenario. The claim would then be billed with the GA modifier.

Q20. If the clinicals don’t state the reason the beneficiary gets a custom brace, can the practitioner’s evaluation provide that information only?
A20. The treating practitioner must provide documentation in the medical record justifying the need for the custom fabricated product rather than the prefabricated brace.

Q21. When the beneficiary receives an AFO prior to the RUL because the brace is broken or worn out, is that a sufficient reason for Medicare to pay for a new AFO?
A21. Normal wear and tear would not meet the criteria for replacement of an AFO prior to the end of RUL.


Last Updated Fri, 08 Oct 2021 12:52:22 +0000