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Spinal Orthoses Questions & Answers (Q&As)

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  1. How should we code a brace that is dispensed with minimal self-adjustment when there is not a corresponding off-the-shelf code? For example, we dispensed a brace that is normally coded L0464 when it is dispensed with substantial modifications by the orthotist. The code description states, "includes fitting and adjustment," but there is not corresponding HCPCS code for "off-the-shelf."

    • HCPCS L0464 and certain other spinal orthoses HCPCS codes are 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, the following miscellaneous code must be used to bill the DME MAC:

      L1499 Spinal orthosis, not otherwise specified

      For more information, see the March 2021 news article: Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code – Correct Coding.

      Reminder: 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 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.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  2. When replacing an item before the five-year reasonable useful lifetime (RUL) and you list the reason for the replacement in the narrative, do you append the RA modifier to the claim as well?

    • Use the RA modifier on DMEPOS claims to denote instances where an item is furnished as a replacement for the same item which has been lost, stolen, or irreparably damaged.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  3. The requirements for custom-fitted specify that it must be done by a certified orthotist or individual with specialized training. However, we were in an audit and they didn't allow documentation of fitting by the licensed practical nurse (LPN), even though the LPN who did the fitting has specialized training. Why isn't the LPN acceptable as a someone with specialized training?

    • "Custom fitting" is defined as changes made to achieve an individualized fit of the item, and it must be performed by someone with the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics and is in compliance with all applicable federal and state licensure and regulatory requirements. Therefore, the individual must have specialized training in the provisions of orthotics and be operating within their scope of practice to provide custom-fitted orthotics. Custom-fit orthotics also requires compliance with Appendix C of the DMEPOS Quality StandardsExternal website. We suggest that you contact your accreditation organization for questions concerning requirements to meet the DMEPOS Quality Standards.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  4. What constitutes "minimal self-adjustment" in determining whether an item is off-the-shelf or custom-fitted?

    • There is no physical difference between orthoses coded as custom-fitted versus those coded as off-the-shelf. The differentiating factor for proper coding is the need for "minimal self-adjustment" at the time of fitting by the beneficiary, caretaker for the beneficiary, or supplier. This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training. For example, adjustment of straps and closures, bending, or trimming for final fit or comfort (not all-inclusive) fall into this category. Minimal self-adjustment can be done by the beneficiary, their caregiver, or the supplier. The Orthotics ChartPDF outlines the difference between minimal self-adjustment and fitting requiring the expertise of a certified orthotist or an individual who has specialized training.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  5. Do the practitioner's notes need to state specifically they are ordering an off-the-shelf brace? Do they need to specify whether it is custom fitted?

    • The medical record must document the need for the brace, not specifically the type of brace. The standard written order should specify the type of brace. When providing these items, suppliers must:

      • Provide the product that is specified by the treating practitioner;
      • Ensure that the treating practitioner's medical record justifies the need for the type of product (such as prefabricated versus custom fabricated);
      • Only bill for the HCPCS code that accurately reflects both the type of orthosis and the appropriate level of fitting; and
      • Have detailed documentation in the supplier's record that justifies the code selected.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  6. For a replacement claim for a lumbar spinal orthosis (LSO ), is weight gain or loss considered a change in medical condition?

    • Yes, weight changes can be considered a medical change of condition. You should include a description of the weight loss or gain. The description should specify the amount of loss/gain, the time frame in which the change occurred, and how that weight loss/gain is preventing the beneficiary from using the current device. Refer to our article on same/similar appeals.

      Also, see the documentation checklist for Replacement Orthotics for Change in Condition During the Reasonable Useful Lifetime.PDF

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  7. What place of service do we use if a brace is delivered in our facility to be taken home?
  8. Can the supplier bill the brace to DME if the physician prescribes it prior to surgery in anticipation of recovery?
      • The brace should not be provided prior to the start of medical necessity.
      • Payment for a spinal orthosis is included in the payment to a hospital or SNF if:
        1. The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and
        2. The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after spinal surgery).

      OR

        1. The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the day of discharge; and
        2. The beneficiary uses the item for medically-necessary inpatient treatment or rehabilitation.

      Payment for a spinal orthosis delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:

        1. The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and
        2. The orthosis is provided to the beneficiary within two days prior to discharge to home; and
        3. The orthosis is not needed for inpatient treatment or rehabilitation but is left in the room for the beneficiary to take home.

      Originally published: 07.23.2021
      Reviewed: 11.14.2024

  9. When is the CG modifier required for spinal orthoses?

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