Noridian, the Jurisdiction A Durable Medical Equipment Medicare Administrative Contractor (DME MAC), released clarification about billing for custom-fitted orthoses when there is no off-the-shelf (OTS) equivalent. When reviewing claims for these items, Noridian said it found that some suppliers have been billing with the supplier’s cost of the item instead of the supplier’s retail price.
When a prefabricated custom-fitted orthosis is being provided directly to a beneficiary and no custom fitting is completed at the time of delivery, the corresponding prefabricated OTS Healthcare Common Procedure Coding System (HCPCS) code must be billed on the claim. When there is not a corresponding prefabricated OTS HCPCS code for the HCPCS categorized as custom-fitted orthotics, one of the following miscellaneous codes must be used for billing:
- L-1499 – Spinal orthosis, not otherwise specified
- L-2999 – Lower-extremity orthoses, not otherwise specified
- L-3999 – Upper-limb orthosis, not otherwise specified
A narrative must be included on the claim line (Item 19 of the 1500 claim form or the 2400/NTE segment of an electronic claim) with the following information:
- HCPCS code of the item being provided
- OTS to indicate it is off-the-shelf
- Supplier’s retail price (SRP)
Noridian provided the following example of a claim line: L-1820 OTS $150 SRP+
