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David McGill Blogger

Orthotics Redefined

Posted by David McGill | February 28, 2014

The Medicare Administrative Contractors issued a joint publication yesterday entitled "Correct Coding - Definitions Used for Off-the-Shelf, Custom Fitted and Custom Fabricated Orthotics (Braces)." In this article, the MACs defined 4 key terms:

  1. off-the-shelf orthotics (prefabricated, require minimal self-adjustment for fitting at the time of delivery)
  2. custom fitted orthotics (prefabricated, require substantial modification for fitting by a qualified practitioner at the time of delivery)
  3. custom fabricated orthotics (uniquely made for an individual beneficiary from basic raw materials before fitting; must be individually fabricated by a qualified practitioner over an actual physical model of the body part;)
  4. qualified practitioner ((1) licensed physician, (2) licensed PT, (3) licensed OT, (4) licensed orthotist or prosthetist in a licensure state, or (5) trained and educated to provide or manage the provision of custom fabricated orthotics and is ABC/BOC-certified or has equivalent specialized training in the provision of custom fabricated orthoses).

IMPORTANT: For the complete definitions of each of the above terms, please refer to the actual MAC update. We have only extracted the key elements here for your convenience.

What does this mean for you?

First, as we've said in previous posts about the new "exploded codes" for orthotics, you (the supplier) must select the correct code. The new definitions make clear that this is a fact-sensitive exercise, dependent on (a) what you do to the product, (b) when you do it, and (c) who does it.

Second, we understand that these definitions might impact historical coding suggestions for certain classes of all orthotic products, including Ossur's. We are reviewing this information in detail and will provide more specific guidance when we have finished our analysis.

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