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David McGill Blogger

Orthoses Defined (Again. Hopefully for the Last Time.)

Posted by David McGill | March 28, 2014

We've reviewed the new "Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics" guidance from the MACs. Here are the 5 key things you need to know.

1. Off-the-shelf orthoses are ...

(A) Prefabricated.

(B) Devices that "require minimal self-adjustment for fitting at the time of delivery for appropriate use."

(C) Items that do not require the expetise of either a certified orthotist on the one hand, or an individual who has "equivalent specialized training" on the other. (More on that in 4, below.)

2. Custom-fitted orthoses are ...

(A) Prefabricated.

(B) Devices that "require[ ] substantial modification for fitting at the time of delivery in order to provide an individualized fit" (trimming, bending, molding, etc.).

(C) Items that do "require [the] expertise of a certified orthotist or an individual who has equivalent specialized training."

3. Certified orthotists are ...

(A) ABC-certified orthotists, or

(B) BOC-certified orthotists.

4. An individual who has "equivalent specialized training" is a person "such as" ...

(A) a physician

(B) a "treating practitioner"

(C) an occupational therapist, or 

(D) a physical therapist. 

5. Suppliers must also ...

Provide the product specificied by the ordering physician. (The physician must specify both the type of device (e.g., AFO, KAFO, spinal orthosis, etc.) and the method of fitting (OTS v. custom-fit).)

What does this all mean for you?

First, in order to distinguish between which of the 2 potentially-applicable L codes applies, you'll have to analyze whether the device "requires minimal self adjustment" (OTS) or "substantial modification for fitting" at the time of delivery (custom-fit). 

Second, if you believe that the device falls within the definition of a "custom-fit" item, you'll have to document that the substantial modifications were performed by either (a) an ABC or BOC-certified orthotist, or (b) someone with "equivalent specialized training," such as a physician, PT, or OT. If you can't document that, Medicare will deny the claim.

Third, the fact that the physician's order must specify whether the device is OTS or custom fit means that you must (a) be able to accurately predict which type the patient will need ahead of time, and (b) delay delivering any prefabricated orthosis to the patient until you've confirmed that the order includes both device type and fitting method, which is a new burden on the supplier.

In summary, your documentation and the prescribing physician's must now clearly demonstrate the need for a custom-fit item if in fact your claim bills for a custom-fit code. In particular, you'll have to show that "substantial modification for fitting" by a person with appropriate credentials supports the delivery of a custom-fit item.

Make sure to read both the LCD and the accompanying policy article to view the complete list of changes that we've summarized here. Also note that these standards apply to all claims submitted after 1/1/2014.

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