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Linda Collins Blogger

A Takes a Step Forward

Posted by Linda Collins | June 06, 2013

What does this mean for you?

First, you have to know the medical necessity requirements for pre-fabricated versus custom braces. Medicare only considers custom braces medically necessary when documentary evidence shows why an off-the-shelf brace will not work for the patient (for example, the patient has a neurological or circulatory condition that requires a custom brace in order to avoid further tissue damage).

If the patient has weakness or deformity, requires joint stabilization, and can functionally benefit from the use of a brace, an off-the-shelf brace is the most appropriate option. In this case, the add-on codes listed below CANNOT be billed with the base code.

L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL,FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY

L4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

Note that all of the above descriptions include the phrase, “for custom fabricated orthosis only,” which is a reminder not to use these codes with off the shelf braces.

Currently this issue is posted for Region A only, but it is likely the other Recover Auditors will follow by example.

For more information, consult the LCD and Policy Articles for your Region (Helpful Links section on left) and the Össur Billing Guidelines for AFO and KAFO (Reimbursement Resources section on the left)

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com