Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Revised

As part of the 2014 HCPCS update codes were created describing certain off-the-shelf (OTS) orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the appropriate Local Coverage Determination (LCD) for a list of codes.

When providing these items suppliers must:
• Provide the product that is specified by the ordering physician, i.e. (1) type of orthosis and (2) 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 these items.  Please click here for more information



The National Uniform Claim Committee (NUCC) recently revised the CMS 1500 claim form. On June

10, 2013, the White House Office of Management and Budget (OMB) approved the revised form,

02/12. The revised form has a number of changes. Those most notable for Medicare are new

indicators to differentiate between ICD-9 and ICD-10 codes on a claim, and qualifiers to identify

whether certain providers are being identified as having performed an ordering, referring, or

supervising role in the furnishing of the service. In addition, the revised form uses letters, instead of

numbers, as diagnosis code pointers, and expands the number of possible diagnosis codes on a claim

to 12.  For additional information please click CMS 1500


Dear Physician,

The DME MAC medical directors frequently receive complaints from physicians about various marketing schemes from DME suppliers.Some of the methods used are:

  • Unsolicited orders for medical equipment or supplies, often with wording such as “We received a call from your patient Jane Doe who wants you to order…” and then lists multiple items on a pre-printed order for you to approve.
  • Advertisements that Medicare will provide you with payment for referrals of patients.
  • Pre-completed medical necessity forms with instructions to just “Sign and Date Here.”

Most of these schemes are obvious in their wording or their attempts to get you to approve unnecessary medical equipment and supplies.You are under no obligation to support or justify these supplier solicitations or to sign orders for items not initiated by you or that were provided by the DME supplier at a patient’s request without prior consultation. Suspected abuse may be reported to the OIG at, 1-800-447-8477 or via fax at 1-800-223-2164.  To read the entire letter please click here

CMS is in the procurement process for the next round of Recovery Audit Program contracts

CMS is in the procurement process for the next round of Recovery Audit Program contracts.  It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program.   Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program.  CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers.  CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders. For additional information please click here Recovery Audit Program.