The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication called “Correct Coding – Definitions Used for Off-the-Shelf, Custom Fitted, and Custom Fabricated Orthotics (Braces)” that provides guidelines for suppliers providing off-the-shelf (OTS) orthoses with parallel codes for custom-fitted versions of the same items. The code descriptors for 23 orthoses were split to describe two delivery methods as part of the January 2014 Healthcare Common Procedure Coding System (HCPCS) updates. The joint publication also provides coding definitions for OTS and custom orthoses.
When providing these items suppliers must comply with the following:
- Provide the product that is specified by the ordering physician, i.e. type of orthosis and method of fitting and/or fabrication (OTS, custom fitted, or custom fabricated).
- Be sure that the medical record justifies the need for the type of product (prefabricated versus custom fabricated).
- Have detailed documentation in your records that justifies the code selected (e.g., fabrication methods and materials used, appropriate level of fitting, and credentials of the individual fabricating and fitting the item).
The following definitions will be used for correct coding of these items:
OTS orthoses: Items that are prefabricated and require minimal self-adjustment for fitting at the time of delivery for appropriate use by the beneficiary. This fitting does not require the expertise of a qualified practitioner.
Custom-fitted orthoses: Items that are prefabricated and require substantial modification for fitting at the time of delivery in order to provide an individualized fit. This fitting requires the expertise of a qualified practitioner.
Custom-fabricated orthoses: Items that are uniquely made for an individual beneficiary, are individually made from basic raw materials prior to fitting on the beneficiary, must be individually fabricated over an actual physical model of the body part, and require the expertise of a qualified practitioner to custom fabricate.
To read the article in its entirety, click here. A summary classification algorithm and a list of the affected codes are included at the end of this document to assist suppliers in determinations about the type of product and correct code selection.