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Linda Collins Blogger

Audit Results for Off the Shelf, Custom Fabricated and Custom Fit Braces

Posted by Linda Collins | August 21, 2014

Region D Noridian recently released the results of prepayment reviews for specific Orthoses codes. The audits included claims with codes:

  • L1960 (AFO custom fabricated)
  • L1970 (AFO custom fabricated)
  • L0637 (SO, custom fitted)
  • L4360 (AFO, custom fitted)
  • L0631 (SO, custom fitted)

The audit results show an improper payment rate ranging from 83.46% to 88.68%. (For detailed results, visit .) One of the main reasons for denials across all these audits is lack of documentation to support medical necessity of the brace.

The Results for Custom-Fabricated Braces

Audits on custom-fabricated codes are not unusual. The Local Coverage Determination outlines the documentation required to justify a custom brace versus an off-the-shelf brace. Specifically, custom-fabricated braces are covered when (1) the beneficiary cannot be fit with a prefabricated version due to a chronic condition that requires control of the joint in more than one plane or (2) there is documented evidence of neurological, circulatory or orthopedic status that requires a custom brace to prevent tissue injury, or (3) there is a fracture with abnormal proportions.

One of the main reasons Medicare denies claims for custom braces is because of a lack of physician’s documentation supporting the need for a custom brace versus an off-the-shelf-brace. When fitting a custom brace, be sure the physician’s prescription specifically states “custom brace” and the physician’s medical records, as well as yours, detail the reasons for a custom brace.

The Results for Custom-Fitted Braces

The custom-fitted codes audited by Region D all require that the item be trimmed, bent, molded, assembled or otherwise customized to fit a specific patient by an individual with expertise. Similar to the custom-fabricated code results, one of the top denial reasons Region D identified for this class of braces was the lack of documentation detailing what was done to the brace that would qualify it as custom fit.

What does this mean for you?

These results show that you must ensure that both the supplier's and doctor's records specify the need for something more complex than an off-the-shelf item. That consists not only of documenting the patient's unique clinical condition, but detailing the actual work performed on the brace to make it either custom fabricated or custom fit. 
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