January 31, 2023
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 (PA) (L0648, L0450, L1832, L1833, and L1851), do not submit PA requests prior to 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 PA. Claims submitted with the ST modifier are subject to 100% prepayment review.
If the item is subject to a competitive bid exception, refer to the following resources:
- DMEPOS Competitive Bidding Program Physicians and Other Treating Practitioners, Physical Therapists, and Occupational Therapists
- DMEPOS Competitive Bidding Program Hospitals That are Not Contract Suppliers
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 to determine if an orthosis is adjunctive to another Part A claim.