Reimbursement&codingNews
CMS Furnishes Final List of Off-The-Shelf Orthotic
HCPCS Codes
On August 12, 2013, CMS issued
guidance identifying specific Healthcare
Common Procedure Coding System
(HCPCS) codes that are considered
Off-The-Shelf (OTS) orthotics. On
December 19, 2013, CMS released its
final OTS HCPCS codes approved by
the HCPCS Alpha Numeric Workgroup
effective January 1, 2014.
Section 1847(a)(2) of the Social Security
Act (the Act) defines OTS orthotics
as those orthotics described in section
1861(s)(9) of the Act for which payment
would otherwise be made under section
1834(h) of the Act, which require
minimal self-adjustment for appropriate
use and do not require expertise in
trimming, bending, molding, assembling,
or customizing to fit to the individual.
Orthotics that are currently paid under
section 1834(h) of the Act and are
described in section 1861(s)(9) of the
Act are leg, arm, back and neck braces.
The Medicare Benefit Policy Manual
(Publication 100-02), Chapter 15, Section
130 provides the longstanding Medicare
definition of “braces.” Braces are defined
in this section as “rigid or semi-rigid
devices which are used for the purpose
of supporting a weak or deformed body
member or restricting or eliminating
motion in a diseased or injured part of the
body.”
Suppliers of any orthotic other than an
OTS orthotic must be in compliance
with Appendix C of the DMEPOS quality
standards, which specifies that suppliers
must possess specialized education,
training, and experience in fitting and
certification and/or licensing.
Note that in some cases there are two
codes in the HCPCS that may both
describe a particular prefabricated
orthotic product, one code for when the
device is furnished OTS, and a second
code for when the device is furnished
with custom fitting. In these cases, and in
the case of any code for a prefabricated
orthotic that requires more than minimal
self-adjustment and requires expertise
in fitting or customizing, the code that
describes a custom fitted orthotic cannot
be used unless the custom fitting services
have been performed and the supplier is
in compliance with Appendix C of the
DMEPOS quality standards.
CMS regulations at 42 CFR 414.402
also define the term “minimal selfadjustment” to mean an adjustment
that the beneficiary, caretaker for the
beneficiary, or supplier of the device
can perform and that does not require
the services of a certified orthotist (that
is, an individual who is certified by
the American Board for Certification
in Orthotics and Prosthetics, Inc., or
by the Board for Orthotist/Prosthetist
Certification) or an individual who has
specialized training.
Visit the Information for DMEPOS
Suppliers section on the PFA website
(www.pedorthics.org) for the complete list
of 2014 Off-the-Shelf Orthotics HCPCS
Codes.
Current Pedorthics
January/February 2014
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