Prior Authorization for Custom Fit and Off-the-Shelf Codes

What You Need to Know

Several prefabricated orthoses can be billed with either a custom fit or OTS code, depending on how the device is fit and delivered to the patient. When both codes for the same device require prior authorization, providers may not know the correct code to submit since they have to obtain approval before delivery. Currently, six of the orthotic codes that require prior authorization have a corresponding custom fit/OTS code also on the list:

• L0631/L0684 - Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design 
• L0637/L0650 - Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design
• L1843/L1851 - Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment

To address this issue, the DME MACs recommend requesting prior authorization for both the custom fit and OTS codes at the same time. Once the orthosis is delivered to the patient, the provider should bill for whichever code is most appropriate based on the adjustments needed to properly fit the device.

 What this Means for You

If your Medicare patient requires a single upright knee orthosis or an LSO with rigid anterior/posterior panels (with or without lateral panels), obtain prior authorization for both the custom fit and OTS HCPCS codes before delivery. Submitting a request for only one code may result in delays and limit your ability to provide patients with the care they need. For example, if you request approval for custom fit code L1843 but substantial modifications are not required, then the appropriate billing code is actually OTS code L1851. In this scenario, the patient would not be able to receive the brace until a new authorization is submitted and approved.

To help improve efficiency within your practice, follow these steps when providing a prefabricated orthosis to a Medicare patient:

1. Determine which custom fit and OTS codes are appropriate for the device.
2. Check if any of the codes are on Medicare's prior authorization list and submit for approval if required.
3. If none of the codes require prior authorization, you can schedule the patient for fit and delivery.
4. If one code requires prior authorization, obtain approval for the single code before delivery.  
5. If both codes require prior authorization (see list above), obtain approval for both codes before delivery.
6. After delivery, submit a claim with either the custom fit or OTS HCPCS code, depending on the modifications required at delivery. Include the Unique Tracking Number (UTN) on the claim if prior authorization is required for the billed code. 

You can find more information about prior authorization for custom fit and OTS codes on the Noridian and CGS websites.