Friday, May 17, 2024

Re: Summary of Responses

Laurie Saunders

Thank you, David, for sharing your responses.

I’d like to follow-up with a response to Joan’s response, and to the entire
list-serve for clarification, because we’ve been given conflicting
information to this.

First, let me address the comment in regards to physician’s notes, we have
been told that the only time you will need to show physician’s notes is not
for a “custom-fitted” device but for a “custom-fabricated” device. Some
people are confusing custom fitted and custom fabricated. One is an OTS
device that needs specific adjustments or modifications that only a
professional in the field should be knowledgeable to make, and the other is
the typical custom device. In the event that you are deciding a custom
device is the only appropriate solution for the patient, or the physician is
specifically requesting a custom device, you should have documentation as to
the reason why. (ie, “patient’s weight requires a custom fabricated carbon
fiber device to ensure stability of the device”). While I have not heard
that MD notes are needed for custom fitted devices over OTS devices, I will
say that we are quickly reaching a point where eventually MD notes will be
required for all claims, custom OR OTS and we should be preparing for this
as an industry. As certain Jurisdictions have already seen, there are
already OTS devices (spinal, knee, and diabetic shoes and OTS OR Custom
inserts) which are requiring MD notes to ensure that the goal of the device
prescribed meets the Medicare LCD’s to justify coverage, and third party
insurances are going to be quick to follow Medicare as we’ve already seen.

Secondly, and the main part I wanted to address in Joan’s statement, and I’m
hoping someone out there can clarify whether they’ve heard the same thing we
have, is that while the OTS and custom-fitted codes are CURRENTLY the same
reimbursements, they do not plan to stay that way. Our reimbursement
specialists have advised us that the OTS codes will eventually fall into a
competitive bidding category, and will be substantially lower reimbursements
than the custom-fitted codes. This will allow the medical supply companies
to continue infringing on the O&P field and bill Medicare for those items
that are currently only reimbursed to licensed Orthotists and Fitters. It
has long been the position of the O&P industry that unlicensed or untrained
personnel should not be able to bill for these items, however, this is a way
that Medicare is allowing US as an industry to begin documenting why any
monkey off the street can’t or shouldn’t deliver these items. The OTS stuff
would be the same type of item that patients could walk into Walgreens and
buy and apply themselves with no adjustments or customizations necessary.
The custom fitted, however, allows O&P personnel to start documenting why
this is something that only O&P providers should be able to carry and bill
for. We’ve been advised to use the custom-fitted codes whenever necessary /
possible, and to advise our practitioners to start including the
modifications made in their note templates or visit notes. If something has
to be repositioned, resewn, rivets added, Velcro extended, heat molded,
flared, shaped, etc. in order for the device to work with the patient, even
the slightest modifications (other than cutting the end of a Velcro strap),
this is essential for us to document. This is setting a precedent to
Medicare that this was not something that “Joe’s Medical Supply Warehouse”
down the road should have been trained to provide. The distinction hasn’t
been made very clearly by Medicare because my guess is they’re hoping to
keep people using the OTS codes, knowing down the road that they will be
lower. The issue comes into play with O&P facilities billing the OTS codes
NOW, and then when the reimbursements go down, they switch to the custom
fitted codes and beef up their documentation then. This will be a red flag
to Medicare who will wonder why the custom fitted codes haven’t been used
all along. We are currently using custom fitted codes whenever we can, and
making sure that our practitioners are making those custom fit
modifications, and MOST IMPORTANTLY documenting them into their notes NOW,
so that a) they are practiced with documenting the need for the custom fit
codes, and b) Medicare is used to seeing us billing those codes regularly,
as opposed to only after the reimbursements change.

Sorry for the long post, but I’m interested to hear if anyone else has heard
the same thing, and to help others decide if they should be using one over
the other when possible. 🙂

Laurie Saunders
Operations Manager

ABC Prosthetics & Orthotics
115 W. Columbia St. Suite A & B
Orlando, FL 32806
Ph. 407.999.8977  Fx. 407.999.0057

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—–Original Message—–
From: Orthotics and Prosthetics List [mailto:[email protected]] On
Behalf Of David Hendricks
Sent: Tuesday, August 02, 2016 3:38 PM
To: [email protected]
Subject: [OANDP-L] Summary of Responses

Last Friday I asked about the purpose of K codes, particularly two that were
brought to my attention: K-0901 & K-0902. Here are the responses. My thanks
to those who responded.

David, Thank you for sharing your file…. In regards to the K code, the
general consensus in the field is that these K codes will eventually be part
of the competitive bidding sector. What we found is that there are several
codes with identical coding except one states “custom fitted” and the other
is a straight OTS code that requires no adjustments. If using the “custom
fitted” code, by policy, we are required to have the MD notes specifically
state that the brace may need custom fitted and we are also required to
explain in our notes exactly how we custom fit the brace in a way that only
a trained specialist could do it (versus the patient). The kicker is the
reimbursement is exactly the same for both the custom fitted code and the
OTS (not custom fitted code). And the OTS equivalent requires NONE of these
added measures. So, why would anyone bill for the custom fitted code? It
only sets you up for added risk of audit, your admin staff has to assure the
MD has documented the need for custom fit and you need to assure that your
practitioners have adequately stated that they used a heat gun or bending
irons or some other tool inaccessible to the average patient. That’s a lot
more work for the exact same allowable. I have my practitioners use the OTS
codes ALWAYS if one is available for the same item. The Kcodes are just the
OTS (i.e. not custom fitted) version of the Lcodes 1843 and 1845.
Joan K. Cestaro, C.P.


They are DME medical equipment and supply codes. Standard DME equipment and
supply codes are either E or K codes.


David Hendricks
David Hendricks, CPO
Blue Diamond Orthopedic
6439 Milner Blvd
Suite 4
Orlando, FL 32809
[email protected]
407-613-2001 Phone
407-613-2010 Fax

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