Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding

Joint DME MAC and PDAC Article

Multiple recent inquires to the Pricing, Data Analysis and Coding (PDAC) Contractor and the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) have demonstrated the need for education regarding the coding and billing of custom fitted orthotics that do not have a corresponding off-the-shelf equivalent. Orthoses are listed on the PDAC website in the HCPCS to Product and Service Code Crosswalk in the following categories of OR01, OR02 and OR03, and are also identified by specific code descriptions (except certain Cervical and Halo Codes in the table below):

• 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)
• OR03 – ORTHOSES: OFF-THE-SHELF
  • PREFABRICATED, OFF-THE-SHELF

There are certain HCPCS codes categorized as OR02 Custom Fitted Orthotics for which there are no corresponding OR03 Off-the-Shelf codes. If a prefabricated orthosis is categorized as Custom Fitted (OR02), but is delivered as Off-the-Shelf, one of the following miscellaneous codes must be used to bill the DME MAC:

L1499 Spinal orthosis, not otherwise specified

L2999 Lower extremity orthoses, not otherwise specified

L3999 Upper limb orthosis, not otherwise specified

Example: A supplier provides a prefabricated device that is listed on the PDAC Product Classification List (PCL) as L3960 (SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT). Two coding options are available for billing this product, based on the actions of the supplier at the time of delivery:

L3960 – Billed if fitting requires alteration beyond minimal self-adjustment (i.e., custom fitting – see below); or,

L3999 – Billed if only minimal self-adjustment adjustment, that can be accomplished by the beneficiary, caregiver or supplier, is necessary.

In this example, when the device requires minimal self-adjustment, the supplier should bill the DME MAC L3999 (Upper limb orthosis, not otherwise specified) because there is not a corresponding prefabricated off-the shelf HCPCS code for L3960.

Custom fitting requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary at the time of delivery. These items cannot be mailed or shipped to the beneficiary [emphasis added] without prior custom fitting of the item. There must be documentation in the orthotist's records to describe how the device was individually fit at the time of delivery to the beneficiary.

Below is a table of 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.

To identify Prefabricated Custom Fitted codes which have a corresponding Prefabricated Off -the-Shelf HCPCS code, suppliers should reference the joint DME MAC article "Definitions Used for Off-The-Shelf versus Custom Fitted Prefabricated Orthotics Braces - Correct Coding - Revised."

If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the page for email inquiry, FAX or postal mail information.