Billing Custom Fit Brace as Off the Shelf

When a HCPCS code is categorized a OR02, orthoses; prefabricated (custom fitted) the product must be billed as custom fit. Per the DME MACs and PDAC, custom fitting requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary at the time of delivery. These items cannot be mailed or shipped to the beneficiary without prior custom fitting of the item. Documentation in the orthotist’s record must describe how the device was extensively modified and uniquely fitted to the individual to be billed as custom fitted.

 If you use provide this item as an off the shelf item, then a miscellaneous code must be used to bill. Specifically, one of the following miscellaneous codes:

•  L1499 (Spinal orthosis, not otherwise specified)
• L2999 (Lower extremity orthoses, not otherwise specified)
• L3999 (Upper limb orthosis, not otherwise specified)

What Does This Mean for You?

Read the advisory article published by the DME MACs. You may access it under the “Medical Directors Articles” section on the DME MAC homepage.  A link to the Noridian article is here. All four DME MACs have published the same article.

The article contains a list of 51 orthotic HCPCS codes classified as custom fit without a corresponding off the shelf code. If you use a product associated with one of these codes, then your documentation must detail the modifications made to the brace and include specifics about who fit the brace. If you do not offer custom fit changes to the brace, then bill it as a miscellaneous code.

Download the Ossur MSRP Billing Guide for more information.