Split Coding…..have you adjusted?

We recently passed the one year mark of the roll-out of CMS’s changes to HCPCS coding for orthotics.  If you have been tracking this issue, you know that CMS made significant changes to the coding structure by establishing two separate categories of HCPCS orthotic codes:  Off-the-Shelf (OTS) and Custom Fitted (CST).  We thought this would be a good time to review these changes and their implications.

As a reminder, the CMS definitions for OTS and CST orthotics are included below:

OTS Orthotics:  Require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Minimal self-adjustment is an adjustment that the beneficiary, caretaker for the beneficiary, or a supplier of the device can perform and that does not require the services of a certified orthotist or an individual who has specialized training.

Custom Fitted Orthotics:  Require fitting by someone with specialized education, training, and experience in fitting and certification and/or licensing.

You can read more about the changes and what it means to you by clicking here, here and here.

If you are a DJO customer you have probably noticed that DJO now lists two recommended HCPCS codes on applicable product labels:  one code for OTS and another for CST.  Each customer should carefully review the CMS requirements to determine which is the most appropriate code to bill.  Although, for now, the Medicare reimbursement for an OTS code is the same as a CST code, you must still meet the Medicare CST requirements when you bill a CST code. Failure to do so could subject you to Medicare repayments and even fines in the face of a Medicare audit.

For commercial payors, this change has created quite a bit of confusion.  While most commercial payors are recognizing the new codes, there are still some that do not.  We recommend that you check with your commercial payors to see how they are addressing the new coding structure.  Depending on what you find out, you may want to check your payor contracts to determine if updates are indicated. For example, are the OTS codes listed and, if so, is there an associated fee schedule?  And don’t forget to audit your payments to ensure you are getting paid appropriately by both Medicare and private payors.

If you would like more information or have questions about these changes please feel free to reach out to your local DJO representative.

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