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Linda Collins Blogger

Replacement Orthoses

Posted by Linda Collins | June 09, 2015

​You provided an Unloader One to a patient two years ago. The patient dutifully wears the brace every day and is experiencing significantly less pain. Today the patient returns to your office with a sad story of losing the brace in a flood. Can you bill Medicare for a new L1843 even though the reasonable lifetime of three years has not been met?

Medicare allows for a replacement orthoses to be provided within the reasonable useful lifetime of the brace under certain situations. If the brace is lost, damaged beyond repair, the cost of repair is greater than 60% of the allowable amount, or there is a documented physiological change in the patient's medical condition, the replacement may be covered.

According to Medicare, irreparable damage is considered when there is a specific incident or accident, such as a natural disaster, documented accident, or documented theft. In all cases, a new physician's order is required to support the continued need of the brace. The medical records must include a reason for the replacement, a statement from the beneficiary about the condition of the irreparable or lost item and police reports, as appropriate. You should also consider photographs of the damaged item if possible.

Medicare makes it clear that wear and tear are not considered irreparable damage. If the brace deteriorates because of day-to-day use, overuse or incorrect use, Medicare will not cover a replacement. In this case, Medicare may approve repair to the item. (See Billing Repairs of Orthoses and Prostheses)

You must use specific modifiers when billing a claim for replacement items provided within the reasonable useful lifetime. Use the HCPCS code, the RT or LT designation if appropriate, and "RA" - Replacement of a DME item. The RA modifier indicates you are replacing the item within the expected lifetime and you have all the documentation to support the item is beyond repair, lost, stolen or there is a documented physiological change to the patient.  

If you bill electronically, replacement items must be specifically notated in the NTE 2300 segment of the electronic claim in order for Medicare to consider coverage. This includes all of the following information:

  • The description of the beneficiary owned base piece of equipment that the item is being replaced on
  • The HCPCS code of the base piece of equipment
  • The date of purchase of the base piece of equipment

Contact Provider Outreach in your MAC for a list of suggested abbreviations to use.

NOTE: We commonly receive questions about the reasonable useful lifetime of prosthetic devices. Prosthetics are not subject to reasonable

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