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.
