The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication for further supplier education about custom-fitted orthoses codes that do not have a corresponding off-the-shelf (OTS) code. Orthoses are identified by specific code descriptions:
- OR01
Orthoses, 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 by the DME MACs)
- OR03
Orthoses, OTS, prefabricated
Some Healthcare Common Procedure Coding System (HCPCS) codes categorized as OR02 have no corresponding OR03 code. If a prefabricated orthosis is categorized as custom fitted (OR02), but is delivered as OTS, 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
The DME MACs gave the following example:
A supplier provides a prefabricated device that is listed on the PDAC Product Classification List as L-3960 (Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and adjustment), and two coding options are available for billing, based on the actions of the supplier at the time of delivery:
- L-3960
Billed if fitting requires alteration beyond minimal self-adjustment (i.e., custom fitting, or
- L-3999
Billed if only minimal self-adjustment, that can be accomplished by the beneficiary, caregiver or supplier, is necessary
In the example, when the device requires minimal self-adjustment, the supplier should bill L-3999 (upper limb orthosis, not otherwise specified) because there is not a corresponding prefabricated OTS HCPCS code for L-3960.
To read the publication, “Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Correct Coding–Revised,” visit the CGS website.
