Correct Coding of a Custom Fitted Orthotic Without Corresponding OTS Code

In March, the DME MACs and PDAC issued a joint notice regarding correct coding for those products that have a custom fit code and are billed as off the shelf. It is important to use the correct HCPCS when billing these products, especially if billed off the shelf.

A bit of background

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 medical 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?

There are 51 HCPCS codes identified that are classified as Custom Fitted Orthotics. Many of the products can be provided as Off the Shelf. Refer to the list of codes to determine if you provide any of these items.

If you do provide one of the items associated with these codes, you need to determine if it is provided Custom Fitted or Off the Shelf.

Custom Fitted devices must have detailed supporting documentation from a qualified provider. If this information is not present in the medical record, the claim may be subject to denial or audit.

If the device is provided as Off the Shelf, then a miscellaneous code must be used on the claim. This applies to all products from all manufacturers.

Össur is committed to providing you with up to date information on coding and claims. Additionally, we provide a plethora of resources to help you bill miscellaneous codes.