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Coding Bulletin Clarifies “Prefabricated, Includes Fitting and Adjustment”

by The O&P EDGE
March 12, 2021
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The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis, and Coding Contractor (PDAC) published a joint coding bulletin regarding the coding and billing of custom-fitted orthoses that do not have a corresponding off-the-shelf equivalent.

Healthcare Common Procedure Coding System (HCPCS) codes that include the term “prefabricated, includes fitting and adjustment” are classified as custom-fitted orthoses and can only be used to describe orthoses that require customization and/or modification by a certified orthotist or other properly trained individual.

Orthosis code categories OR01, OR02 and OR03 are identified by specific code descriptions:

·       OR01 (orthoses: custom fabricated)

Custom fabricated, includes fitting and adjustment

·       OR02 (orthoses: prefabricated (custom fitted))

Prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Prefabricated, includes fitting and adjustment (emphasis added in the joint bulletin)

·       OR03 (orthoses: off-the-shelf)

Prefabricated, off-the-shelf

Some HCPCS codes categorized as OR02 (custom-fitted orthotics) have no corresponding OR03 (off-the-shelf) codes. If a prefabricated orthosis is categorized as OR02, but is delivered as off-the-shelf, one of the following miscellaneous codes must be used to bill the DME MAC:

·       L-1499 (spinal orthosis, not otherwise specified)

·       L-2999 (lower-extremity orthoses, not otherwise specified)

·       L-3999 (upper-limb orthosis, not otherwise specified)

To read the bulletin or for a list of the HCPCS codes that are classified on the “HCPCS to Product and Service Code Crosswalk” as OR02: Prefabricated (Custom Fitted) where there is no corresponding Prefabricated Off-the-Shelf HCPCS code, visit the Noridian website.

Related posts:

  1. Noridian Clarifies Orthotic Billing
  2. Revised: DME MACs Provide Coding Definitions for OTS, Custom Orthoses
  3. DME MACs Provide Coding Definitions for OTS, Custom Orthoses
  4. Coding Verifications Deleted for AFOs
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