Off the Shelf vs Custom Fit Braces: Coding

The DME MACs have revised the definitions of Off the Shelf and Custom Fitted braces. The new definitions can be found in the LCD and Policy Article.

The definition for off the shelf (OTS) orthotics is:

• The item is prefabricated
• The item requires minimal self-adjustment for fitting
• The fitting does not require the expertise of a certified orthotist.

The MACs further clarify "minimal self-adjustment"  is an adjustment that can easily be done by the patient, a caretaker, or supplier of the device.

The custom-fit orthotics are defined as:

• The item is prefabricated
• The item requires more than minimal self-adjustment at time of delivery.
• The fitting at delivery does require the expertise of a certified orthotist.

More than minimal self-adjustment are changes made to fit the device to the patient and the adjustments do require the expertise of a certified orthotist. The item is trimmed, bent, molded, assembled or otherwise custom fitted to the specific patient.

What does this mean for you?

When billing for an orthotic that may be either OTS or custom-fit, be sure to use the correct HCPCS code. If you use a custom fit brace, the documentation must detail the modifications made.

For more information, including a chart of the parallel codes, read this article.