Upper Limb Orthotics Questions & Answers (Q&As)
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- Do all prefabricated upper limb orthotics have two HCPCS codes: one for off-the-shelf (OTS) and another for custom fit?
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No. There are only seven (7) devices that have different codes according to whether or not they are custom fit or OTS.
Item
Custom-fitted
OTS
SHOULDER ORTHOSIS
L3677
L3678
ELBOW ORTHOSIS (EO)
L3760
L3761
WRIST HAND FINGER ORTHOSIS
L3807
L3809
WRIST HAND ORTHOSIS
L3915
L3916
HAND ORTHOSIS
L3917
L3918
HAND FINGER ORTHOSIS, W/O JOINTS
L3923
L3924
HAND FINGER ORTHOSIS, W/JOINT(S)
L3929
L3930
For more information, read “Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Correct Coding – Revised.”
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- How do I know if a prefabricated orthosis should be billed as OTS (off-the-shelf) or custom fit?
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If an orthosis needs only minimal self-adjustment for fitting at the time of delivery, then it is considered OTS. However, if it requires more than minimal self-adjustment, it is considered custom fit. Additionally, refer to “Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code – Correct Coding” to understand if an orthosis is classified in the HCPCS to Product and Service Code Crosswalk as a device that requires custom fitting, or if the device has an off-the-shelf and custom fit corresponding HCPCS codes.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- What does “minimal self-adjustment” mean?
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“Minimal” refers to adjustments that can be made by the beneficiary, their caregiver, or the supplier, such as assembling, trimming, or adjusting straps. Minimal self-adjustment does not require any expertise in trimming, molding, assembling, or customizing fit to the individual; therefore, the adjustment does not need to be performed by a certified orthotist or an individual with specialized training.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- What is considered “more than minimal?”
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More than minimal self-adjustment is when an item must be trimmed, bent, molded, or otherwise modified for an individualized fit. These kinds of alterations require the expertise of a certified orthotist or someone with specialized training in the provisions of orthoses to fit the item to the beneficiary.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- What details do I need in the documentation regarding custom fitted orthotics?
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Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- Who is qualified to make the modifications required for a custom fitted orthotic?
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Modification for a custom fitted orthotic requires an individual who has specialized training in the provision of orthotics in compliance with all applicable federal and state licensure and regulatory requirements. Custom fitted requires the expertise of a certified orthotist or equivalent training (MD, NP, PA, PT, OT, etc.) and their signature.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- Does assembling an orthotic from a kit or with add-on components qualify as “custom fitted?”
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No. Assembly of a kit, installation of add-on components, and/or the use of basic materials in preparation does not classify as custom fitted.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- What is the definition of custom fabricated?
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A custom fabricated item is individually made for a specific beneficiary. No other beneficiary can use that item. Custom fabricated devices use clinically derived and rectified castings, tracings, measurements, and/or other body part images, such as X-rays. This process uses basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of uncut or unshaped sheets, bars, or other basic forms. It also involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing before a beneficiary fitting.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- Can I provide an upper extremity orthosis to a beneficiary in the hospital or skilled nursing facility (SNF)?
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It depends on the circumstances. An orthotic would be included in the payment to a hospital or SNF as follows:
- Orthosis is provided to a beneficiary prior to or during an inpatient hospital admission or a Part A covered SNF stay; or
- The medical necessity for the orthosis begins during the hospital or SNF stay; or
- The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- When can I bill the DME MAC for an upper limb orthosis to a beneficiary in the hospital or skilled nursing facility?
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For a beneficiary in the hospital or skilled nursing facility, the ULO is eligible for coverage by the DME MAC if:
- The orthosis is medically necessary after discharge; and
- The orthosis is provided to the beneficiary within two days prior to discharge for the purposes of fitting and training; and
- The orthosis is not needed for inpatient treatment or rehab but left in the room for the beneficiary to take home.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- A treating practitioner ordered a HCPCS that falls into the OTS category, but the orthotist made substantial modifications at the time of delivery. Can we bill the custom fitted HCPCS code instead?
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Yes, if the modifications go beyond minimal self-adjustment and require the expertise of a certified orthotist or an individual with specialized training in trimming, molding, assembling, or customizing fit to the individual. You must have detailed documentation of the modifications necessary at the time of fitting, the qualifications of the individual who made the modifications, and their credentials and signature.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- Does a supplier need a new order if the item was ordered as OTS, but then needs to be custom fitted?
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No, since the OTS and custom fitted items are physically the same device and only distinguished, for the purpose of billing, based on the orthotist’s fitting, the original order indicating an OTS orthosis will suffice.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- How can I find out what items can be billed with the HCPCS L3960 for a shoulder-elbow-wrist-hand orthosis?
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As of August 1, 2020, the only products which may be billed using code L3960 are those for which a written coding verification review has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor, and subsequently published on the appropriate Product Classification list. See “L3960 – Coding Verification Review Requirement.”
Originally published: 11.09.2021
Reviewed: 12.03.2024
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- Where can I find the PDAC Product Classification List?
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The Product Classification List is on the PDAC website
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Originally published: 11.09.2021
Reviewed: 12.03.2024
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- I have a beneficiary whose upper limb orthosis (ULO) is simply worn out. Can I replace it?
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Replacement of orthotics is governed by reasonable useful lifetime (RUL) regulations at 42 CFR 414.210 and in the absence of program instructions, the RUL can be no less than five (5) years. Replacement of an item prior to the 5 year RUL may be made only in the case of items that are lost, stolen or irreparably damaged. Items that are “worn out” are not eligible for replacement prior to the 5-year RUL.
Originally published: 11.09.2021
Reviewed: 12.03.2024
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For more information, please refer to “Correct Coding of Finger, Hand, Hand-Finger and Wrist-Hand-Finger Braces (Orthoses).”