Billing Instruction for Prefabricated Braces Without an OTS code

Over the years there have been many changes to the HCPCS coding for orthoses. With the most recent overall CMS established two L code sets; Prefabricated and Custom Fabricated. A prefabricated orthosis may be considered an off the shelf (OTS) or a custom fitted device that may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific beneficiary. Prefabricated orthoses fall under two categories; OR02 custom fitted or OR03 – OTS. There is no physical difference between prefabricated orthoses coded as custom fitted versus those coded as OTS. The differentiating factor for proper coding is the adjustment needed at the time of fitting. For OTS, minimal self-adjustment by the beneficiary, caretaker or the supplier is required but does not require the services of a certified orthotist of an individual who has specialized training. Custom fitted requires the expertise of a certified orthotist or an individual who has specialized training to adjust the orthotic specific to the patient’s need. The challenge is that there are custom fitted orthotics that do not have a corresponding off-the-shelf equivalent HCPCS code.

On March 11, 2021, the DME MACs and the PDAC published a joint article titled “Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code – Correct Coding. ” In the article¹, Medicare lists multiple custom fitted codes that do not have an equivalent OTS code.

On May 25, 2021, Medicare announced additional payment edits for DMEPOS suppliers of custom fabricated and prefabricated (custom fitted) orthotics – CR 12282 – Updated on September 14, 2021. The article² lists 21 states where the supplier must have a licensed/certified orthotist or prosthetist on file in order to provide custom fitted and custom fabricated orthotics. The edits were turned on effective for dates of service on or after October 01, 2021. In all the cases I have reviewed, the claims were denied because the suppliers had no intentions of providing custom fitted orthoses since they did not have OR02 selected on their 855s but since there is no physical difference in orthoses between the custom fitted and the OTS, they bill the coded provided to them by the manufacturer. The good news is these denials can be corrected and prevented.

On May 07, 2021, Medicare clarified the correct way to bill these custom-fitted-codes as OTS. Specifically, the article³ states “when there is not a corresponding prefabricated off-the-shelf HCPCS code for the HCPCS categorized as Custom Fitted Orthotics, one of the following miscellaneous codes must be used for billing.

L1499 – Spinal orthosis, not otherwise specified.
L2999 – Lower extremity orthoses, not otherwise specified.
L3999 – Upper limb orthosis, not otherwise specified.

A narrative must be included on the claim with the following information.

HCPCS code of item being provided
OTS to indicate it is off the shelf
Supplier’s Retail Price (SRP)

Example: L1820 OTS $150 STRP

Suppliers who followed this instruction have been successful at getting payment as OTS. ACU-Serve encourages suppliers to self-audit to ensure they compliance with this billing guidance. If the supplier is signed up for OR02 and OR03, the claims will not be denied but the billing error still remains as suppliers would not have documentation to support the need for custom fitted orthoses over the OTS. In other words, suppliers registered for both OR02 and OR03 cannot rely on the Medicare system to catch these billing errors. Suppliers should ensure their billing staff is aware of these billing rules and conduct self-audit for compliance. Suppliers should be mindful it is unlikely mail order orthoses will meet the “custom fitted” requirement as patients or caregiver cannot perform the modification needed to qualify as custom fitted. Suppliers with consignment closet arrangement should also be aware of this as it might be impractical to custom fit or modify braces delivered to patients under the consignment arrangement.

If you have additional questions or concerns, please do not hesitate to contact Noel Neil directly at [email protected].

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