Custom Fit Orthoses

What You Need to Know

Orthotic HCPCS codes are split into two main categories: prefabricated and custom fabricated. The prefabricated orthoses are further categorized as either off-the-shelf (OTS) or custom fit. OTS orthoses require “minimal self-adjustment” at the time of fitting by the beneficiary, caretaker, or supplier (i.e., adjusting straps/closures or trimming the orthosis for comfort). Conversely, custom fit orthoses require "more than minimal self-adjustment" [emphasis added] at the time of delivery to provide an individualized fit, which requires the expertise of a certified orthotist or individual who has specialized training in the provision of orthoses. The Spinal, Knee, and Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Articles define specialized training as "training that provides the knowledge, skills, and experience in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements." The Correct Coding Guidance posted by the DME MACs further expands upon the definitions of OTS and custom fit orthoses. 

After determining whether a prefabricated orthosis was delivered as an OTS or custom fit device, it is important to use the correct HCPCS code for billing. There are several prefabricated devices that have parallel HCPCS codes, and the exact same device can be billed with either the OTS or custom fit code. The provider is responsible for determining which code is most appropriate based on the definitions outlined above. These code descriptions start out the same, but the endings are different:

• OTS ending: "PREFABRICATED, OFF-THE-SHELF"
• Custom fit ending: "PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE." 

A table with all the parallel codes can be found here. 

There are also several prefabricated HCPCS codes that only describe custom fit orthoses and do not have an OTS equivalent code. If you provide an orthosis that does not have an OTS code but only "minimal self-adjustment" was performed at delivery, you must bill using the appropriate miscellaneous code (L2999, L3999, or L4999). These custom fit code descriptions typically end with "PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT." A list of custom fit only codes can be found here, and further instructions on billing miscellaneous codes for OTS devices can be found here. 

What this Means for You

Selecting the correct HCPCS code for a prefabricated orthosis depends on the actions that occur during the fitting appointment and is either considered custom fit (requiring expertise) or OTS (requiring minimal self-adjustment). Once a provider determines that a prefabricated orthosis was custom fit, it is imperative that they thoroughly document why the orthosis qualifies as custom fit. TPE and CERT audit results for custom fit knee and spinal orthoses consistently show that one of the top reasons for denial is a "failure to document more than minimal self-adjustment." The Spinal, Knee, and Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Articles specifically state, “documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary. This information must be available upon request.” Because prefabricated orthoses have two potentially appropriate HCPCS codes, the fitting/delivery note is the only way to justify that you are billing the correct code. Therefore, coverage for a custom fit orthosis relies heavily on thorough documentation. 

Providers need to document, in detail, all modifications they made to the prefabricated orthosis during the fitting appointment (i.e., trimming, bending, molding, assembling, etc.). Avoid vague language and be as descriptive as possible, including what tools and/or measurements were used to make the adjustments. To prove that the modifications were "more than minimal self-adjustment," focus on why the adjustments required an individual with expertise and how the adjustments resulted in an individualized fit to the patient. It is also important to explain why the modifications performed are medically necessary for this patient. Describe any unique anatomy the patient has and what specific modifications were made to accommodate, support, and/or correct the patient's presentation. A provider should also document why an OTS orthosis is not appropriate for the patient (i.e., an improper fit resulting in pain, does not provide appropriate support and compromises function of the orthosis, etc.). Another way to think about the “why” is to explain what negative impacts these modifications are preventing and/or why they are needed for proper function of the orthosis.

Remember, if you cannot justify or document that the orthosis was custom fit to the patient at delivery, then you need to bill with an OTS code. For devices without a parallel OTS code, a miscellaneous orthosis code is most appropriate. If you are still having trouble determining whether a specific HCPCS code is considered OTS or custom fit, you can use this tool for guidance.