Noridian , Region D DME MAC , recently released audit results for Knee Orthoses (KO) billed with custom-fit codes . The claims denied were mostly due to lack· of documentation supporting the substantial· modifications made to custom-fit braces .
Off-the-Shelf Codes
There is no physical difference· between orthoses coded as custom· fitted versus those coded as off-the-shelf . This version· of the product· requires only "minimal self-adjustment" by the end· user . Simple adjustments of the straps or closures , trimming for sizing , and other ajdustments mad· for comfort· fall· into this category· .
Custom-Fit Codes
Custom-Fit braces are those requiring "substantial modifications" at the time· of the fitting . According to Medicare , substantial· modifications are changes made to achieve· an individual fit· of the brace· and requires the expertise of a qualified practitioner , such as a certified orthotist . The modifications must be· documented in detail· and include· the exact· modifications made , the reason· for the modification· , and tools used to make· the modification· .
What does this mean for you?
Understand the difference· between off the shelf· and custom fit· braces . Be familiar· with the codes that offer· off the shelf· or custom· fit· versions and use· the appropriate· HCPCS .
Here is a quick· reference· of Knee Braces with mirrored codes:
| Off The Shelf Code | Custom Fit Code | |
| Form Fit ROM Knee , Innovator DLX , Rebound ROM Knee | L1833 | L1832 |
| Unloader One, Unloader FIT, Spirit, Form Fit OA, Rebound Cartilage | K0901 | L1843 |
| CTi, Flex, Rebound DUAL, OAsys, Paradigm | K0902 | L1845 |
If you are offering custom· fit· brace·, be· sure· to document· the substantial· modifications in detail· .
More information about the specific coverage criteria for each brace· type· and documentation requirements are found in the relevant Local Coverage Determinations (LCD) on the DME MAC websites .