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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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January 31, 2023 - Revised 12.21.23

Providing Orthoses Prior to Surgery – Reminder

CGS wants to remind suppliers and providers that orthotic devices are not covered if they do not meet the coverage criteria outlined in the Local Coverage Determinations (LCDs) for the HCPCS code prescribed at the time of service.

Devices provided prior to the start of medical necessity (for example, before the surgery), will not meet the coverage criteria. After surgery, if there is documentation of the medical necessity for the orthotic device(s), you can provide the item, keeping in mind there are many other payment rules related to the claim.

For orthotic devices that require prior authorization, do not submit prior authorization requests before the start of medical necessity (for example, before the surgery). After surgery, if the medical record documentation shows an emergent need for the device(s), you can submit an expedited request. If an expedited request is not feasible, append the ST modifier to the claim to bypass prior authorization. Claims submitted with the ST modifier are subject to prepayment review.

All orthoses are subject to the hospital outpatient prospective payment system (OPPS) and Part A covered stays included in the skilled nursing facility (SNF) and hospital prospective payment system (PPS) rate. Refer to the Claims Processing Manual (CMS Pub. 100-04), Chapter 20

Dates of service January 1, 2021 – December 31, 2023:

If the item is subject to a competitive bid exception, refer to the following resources:

Publication History:

January 31, 2023:	Original publication date
December 21, 2023:	Revised due to the temporary gap in the Competitive Bidding Program (CBP). Added date of service January 1, 2021 – December 31, 2023.