The four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication called “Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Revised – Joint DME MAC Publication” 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:
- Provide the product that is specified by the ordering physician, i.e. type of orthosis and method of fitting (OTS or custom fitted).
- Be sure that the medical record justifies the need for the type of product and method of fitting.
- Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting.
- Have detailed documentation that justifies the code selected for custom fitted versus OTS codes.
The following definitions will be used for correct coding of OTS orthotics:
- OTS orthotics are prefabricated.
- OTS orthotics may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
- OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual.
- The fitting of OTS orthotics does not require the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual beneficiary.
- The following definitions will be used for correct coding of custom-fitted orthotics:
- Custom-fitted orthotics are prefabricated.
- Custom-fitted orthotics may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
- Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
- This fitting at delivery requires expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary.
The joint publication also notes that use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as custom fitted if the final fitting upon delivery to the patient requires substantial modification requiring expertise as described.
