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David McGill Blogger

Code Confusion & OTS Orthotics: What Can You Do?

Posted by David McGill | April 10, 2014

Last week, the PDAC announced its approach to clarifying some of the coding confusion created by CMS's changes to the orthotic coding system. In this post, we (1) review those changes, (2) summarize the PDAC's plan, and (3) assess its impact on you.

1. The Changes Explained (Again)

Effective January 1, CMS split the category of prefabricated orthoses into two distinct categories: off-the-shelf, and custom-fit. The code language describing an OTS and a custom-fit product is identical, save for the inclusion of the "OTS" or "custom-fit" tag at the end of the descriptor. In other words, the same product could be either OTS or custom-fit.

At the same time, CMS changed the language of 6 additional L-codes to make them "custom-fit" only. Those 6 codes have no OTS corollary - they describe devices that, according to CMS, can only be fit as custom-fit items.  

2. The PDAC's Plan

The PDAC has previously issued coding verifications for many of the products described by these 29 codes. But as the PDAC notes in its recent update

products that are currently listed on the Durable Medical Equipment Coding System (DMECS) with any of the 29 HCPCS codes that were revised can no longer be considered fully "code verified" by the PDAC under the new definitions. While the product(s) fits the general category of its currently designated HCPCS code, the PDAC needs to further differentiate if products are only OTS, only custom-fitted, or possibly both. [Emphasis added]


The PDAC's current plan is to contact manufacturers of the affected products over the next several months and ask them which of their products they believe are only OTS. In the meantime, it has instructed manufacturers not to submit updated coding verification applications for these products.

3. What does this mean for you?

So how do you deal with affected products that are PDAC verified between now and the time several months from now that the PDAC updates its verifications? The best advice we can give at this point is to pay careful attention to what you do to a device before delivery and who does it. The primary distinction between an OTS and custom-fit product is whether the device involves "minimal self-adjustment" (for OTS) or "substantial modifications" (for custom-fit). 

OTS items require "minimal self-adjustment" for fitting at the time of delivery and do not require expertise in bending, molding, assembling or customizing to fit an individual. OTS items do not require the expertise of a certified orthotist or an individual with equivalent specialized training.

Custom-fit items require "substantial modification" for fitting at the time of delivery in order to provide an individualized fit. This means the item must be trimmed, bent, molded, or otherwise modified resulting in alterations beyond minimal self-adjustment. Custom-fit items require the expertise of a certified orthotist or an individual with equivalent specialized training. (Equivalent specialized training includes professionals such as physicians, physical therapists, occupational therapists, and "treating practitioners." (Our current understanding of the term "treating practitioner" is that it refers to individuals that, like MD's, PT's, and OT's, are licensed medical professionals, such as physicians' assistants. However, Medicare has not issued specific guidance on this point.))

As we've said before in this space, based upon these definitions, the correct code for a specific item delivered to a Medicare beneficiary will depend on which of the above definitions you satisfy and can document in the medical record. The recent updates to the LCD's for products affected by these changes support our previous guidance. The LCD's state that when supplying these items, suppliers must:

  • Provide the product that is specified by the ordering physician, i.e., (1) type of orthosis and (2) method of fitting (OTS or custom fitted)
  • Be sure that the medical record justifies the need for the type of product and method of fitting
  • Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting
  • Have detailed documentation that justifies the code selected for custom fitted versus OTS codes.

Conclusion

The world of orthotic coding for the 29 codes affected by CMS's January 1 changes has gotten more complex and confusing. Until the PDAC can provide greater clarity, it's essential that you review the LCD's (quoted in part, above) for affected devices. Ask yourself, "What was done to the brace to fit it on the patient and who did it?" Cross-reference that information to the definitions of OTS and custom-fit devices. Only then should you code and document accordingly.

We will keep you posted as additional information on this topic becomes available. 

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