CMS L-Code List proposed for OTC

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Posted By Bremer Group on 2/13/2012 11:54:01 AM
Dear Orthotic Provider:

We need to send our comments on the recent list published by CMS of possible “OFF THE SHELF” orthotics that would be subject to COMPETITIVE BIDDING. If this list is unchallenged, it would mean that these items could be supplied by non -trained personnel or directly to the patient by mail order, and would not need an orthotist or orthotic fitter to supply it.

Although these items are not currently subject to Competitive bidding , this is a preliminary step to include prescription only, L-coded, prefabricated (used to be called CUSTOM FIT) orthotics, that require specific anatomical landmarks to be met, and which also require fitting and adjustment in the OFF THE SHELF category and make them available for the Competitive bid process. This would effectively eliminate any reimbursement for the service rendered for these braces.

Our comments need to be in by March 8, 2012. I would also use your own e-mail program to send (just cut and paste the address below into your “to” space), so you have a record of your comment. If you send through the CMS website there does not seem to be a receipt of sending it.

Below is the address where you can go to see the 4 and ¼ pages of L-codes that are being considered for the OFF THE SHELF category:

Attached below is the body of this CMS Memo. You can find the list of proposed OFF THE SHELF L-codes in a Zip file at the above address. Also attached is a copy of the e-mail sent today.

Off-The-Shelf (OTS) Orthotic HCPCS Codes

Section 1847(a)(2) of the Social Security Act (the Act) defines OTS orthotics as those orthotics described in section 1861(s)(9) of the Act for which payment would otherwise be made under section 1834(h) of the Act, which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. Orthotics that are currently paid under section 1834(h) of the Act and are described in section 1861(s)(9) of the Act are leg, arm, back and neck braces. The Medicare Benefit Policy Manual (Publication 100-02), Chapter 15, Section 130 provides the longstanding Medicare definition of "braces." Braces are defined in this section as "rigid or semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body."

CMS regulations at 42 CFR 414.402 also define the term "minimal self-adjustment" to mean an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.

The download section of this web page contains a list that initially identifies the 2012 Healthcare Common Procedure Coding System (HCPCS) codes that are considered OTS orthotics. Items classified under these codes require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Please note that the inclusion of a HCPCS code on the OTS orthotics list does not imply any health insurance coverage. Subsequent coding updates to the OTS list will be included in program instructions.

Section 1847(a)(2) of the Act includes OTS orthotics as one of the categories of items subject to competitive bidding. OTS orthotics are not a product category for the Round 2 and National Mail-Order Competition. CMS has not determined the schedule for bidding OTS orthotics, but will identify the specific OTS orthotic codes included in a competitive bidding program through program instructions or by other means, such as a CMS or contractor website posting.

CMS will accept electronic comments on the list of OTS HCPCS codes through Thursday, March 8, 2012. Comments may be submitted via email to [Email Address Removed].

Our e-mail to CMS;

The HCPCS Codes L0637, L0639, L0460 (among others listed) are not " OFF THE SHELF" items as defined in Section 1861(s)(9) and for that reason SHOULD NOT be subject to competitive bidding.

The braces in these codes cannot be properly fitted by a "minimal self adjustment" They require specialized training and skill to trim, bend, cut , or build from components ,etc. to assure they are properly fit within the anatomical landmarks described in their HCPCS code. (i.e.For the L0639 the fitted brace must "extend from sacrococcygeal junction to the T-9 Vertebra, Anterior exrtends from Symphysis Pubis to Xyphoid...") Unless the patient or his caretaker has orthotic or medical training they would not be able to assure these landmarks are met.

These codes also require "Fitting and Adjustment" This requirement presuppose that the patient will be followed up and the brace will be adjusted as the patient wears it and their shape or condition changes. Patients are often in these braces for months and their shape can change from large amount of weight gain or loss , or from changes in swelling or wounds sustained from injury ,surgery, or other factors, . The OFF THE SHELF Category was never envisioned to expect this amount of expertise from the patient or their loved one.

Most importantly, a person who does not have the specialized training to follow up the patient in these types of orthotics, and are unable to check for possible complications from an improperly fit or adjusted brace, can actually do harm to the patient. These are not "OFF THE SHELF" and on the patient products.

Ross L. Bremer, CPO, LPO

The Bremer Group


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