CORRECT CODING – DEFINITIONS USED FOR OFF-THE-SHELF VERSUS CUSTOM-FITTED PREFABRICATED ORTHOTICS (BRACES) – REVISED

Joint DME MAC Publication

This is a revision to a previously published article 3/28/2014.

As part of the 2014 and 2015 HCPCS update, codes were created describing certain OTS orthotics. Some of these codes parallel codes for custom fitted versions of the same items. Refer to the table at the end of this article for a listing of codes.

When providing these items suppliers must:

  • Provide the product that is specified by the ordering physician
  • Be sure that the ordering physician’s medical record justifies the need for the type of product (i.e., prefabricated versus custom fabricated)
  • Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting
  • Have detailed documentation in the supplier’s record that justifies the code selected

Please click here to read the entire article

 

Widespread Prepayment Probe for HCPCS Code L4360 (Pneumatic Walking Boot)

DME MAC A will be initiating a widespread prepayment probe of claims for the following HCPCS code:

L4360 (WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)

This review is being initiated due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.  Please click here to see entire article: L4360 Probe