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Linda Collins Blogger

Off the Shelf and Custom Fit Knee Braces

Posted by Linda Collins | October 04, 2016

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 L1833L1832
Unloader One, Unloader FIT, Spirit, Form Fit OA, Rebound CartilageK0901L1843
CTi, Flex, Rebound DUAL, OAsys, ParadigmK0902L1845

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 . ​

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